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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 PMCID: PMC11297425 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R. Mayer
- Mind Research Network, 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | | | - Joshua Marquez
- University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C. Stevenson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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Svedung Wettervik T, Beqiri E, Hånell A, Bögli SY, Placek M, Donnelly J, Guilfoyle MR, Helmy A, Lavinio A, Hutchinson PJ, Smielewski P. Visualization of Cerebral Pressure Autoregulatory Insults in Traumatic Brain Injury. Crit Care Med 2024; 52:1228-1238. [PMID: 38587420 DOI: 10.1097/ccm.0000000000006287] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/09/2024]
Abstract
OBJECTIVES The first aim was to investigate the combined effect of insult intensity and duration of the pressure reactivity index (PRx) and deviation from the autoregulatory cerebral perfusion pressure target (∆CPPopt = actual CPP - optimal CPP [CPPopt]) on outcome in traumatic brain injury. The second aim was to determine if PRx influenced the association between intracranial pressure (ICP), CPP, and ∆CPPopt with outcome. DESIGN Observational cohort study. SETTING Neurocritical care unit, Cambridge, United Kingdom. PATIENTS Five hundred fifty-three traumatic brain injury patients with ICP and arterial blood pressure monitoring and 6-month outcome data (Glasgow Outcome Scale [GOS]). INTERVENTION None. MEASUREMENTS AND MAIN RESULTS The insult intensity (mm Hg or PRx coefficient) and duration (minutes) of ICP, PRx, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In these plots, there was a transition from favorable to unfavorable outcome when PRx remained positive for 30 minutes and this was also the case for shorter durations when the intensity was higher. In a similar plot of ∆CPPopt, there was a gradual transition from favorable to unfavorable outcome when ∆CPPopt went below -5 mm Hg for 30-minute episodes of time and for shorter durations for more negative ∆CPPopt. Furthermore, the percentage of monitoring time with certain combinations of PRx with ICP, CPP, and ∆CPPopt were correlated with GOS and visualized in heatmaps. In the combined PRx/ICP heatmap, ICP above 20 mm Hg together with PRx above 0 correlated with unfavorable outcome. In a PRx/CPP heatmap, CPP below 70 mm Hg together with PRx above 0.2-0.4 correlated with unfavorable outcome. In the PRx-/∆CPPopt heatmap, ∆CPPopt below 0 together with PRx above 0.2-0.4 correlated with unfavorable outcome. CONCLUSIONS Higher intensities for longer durations of positive PRx and negative ∆CPPopt correlated with worse outcome. Elevated ICP, low CPP, and negative ∆CPPopt were particularly associated with worse outcomes when the cerebral pressure autoregulation was concurrently impaired.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Neurology, Auckland City Hospital, Auckland, New Zealand
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Andrea Lavinio
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Hong E, Froese L, Pontén E, Fletcher-Sandersjöö A, Tatter C, Hammarlund E, Åkerlund CAI, Tjerkaski J, Alpkvist P, Bartek J, Raj R, Lindblad C, Nelson DW, Zeiler FA, Thelin EP. Critical thresholds of long-pressure reactivity index and impact of intracranial pressure monitoring methods in traumatic brain injury. Crit Care 2024; 28:256. [PMID: 39075480 PMCID: PMC11285281 DOI: 10.1186/s13054-024-05042-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2024] [Accepted: 07/16/2024] [Indexed: 07/31/2024] Open
Abstract
BACKGROUND Moderate-to-severe traumatic brain injury (TBI) has a global mortality rate of about 30%, resulting in acquired life-long disabilities in many survivors. To potentially improve outcomes in this TBI population, the management of secondary injuries, particularly the failure of cerebrovascular reactivity (assessed via the pressure reactivity index; PRx, a correlation between intracranial pressure (ICP) and mean arterial blood pressure (MAP)), has gained interest in the field. However, derivation of PRx requires high-resolution data and expensive technological solutions, as calculations use a short time-window, which has resulted in it being used in only a handful of centers worldwide. As a solution to this, low resolution (longer time-windows) PRx has been suggested, known as Long-PRx or LPRx. Though LPRx has been proposed little is known about the best methodology to derive this measure, with different thresholds and time-windows proposed. Furthermore, the impact of ICP monitoring on cerebrovascular reactivity measures is poorly understood. Hence, this observational study establishes critical thresholds of LPRx associated with long-term functional outcome, comparing different time-windows for calculating LPRx as well as evaluating LPRx determined through external ventricular drains (EVD) vs intraparenchymal pressure device (IPD) ICP monitoring. METHODS The study included a total of n = 435 TBI patients from the Karolinska University Hospital. Patients were dichotomized into alive vs. dead and favorable vs. unfavorable outcomes based on 1-year Glasgow Outcome Scale (GOS). Pearson's chi-square values were computed for incrementally increasing LPRx or ICP thresholds against outcome. The thresholds that generated the greatest chi-squared value for each LPRx or ICP parameter had the highest outcome discriminatory capacity. This methodology was also completed for the segmentation of the population based on EVD, IPD, and time of data recorded in hospital stay. RESULTS LPRx calculated with 10-120-min windows behaved similarly, with maximal chi-square values ranging at around a LPRx of 0.25-0.35, for both survival and favorable outcome. When investigating the temporal relations of LPRx derived thresholds, the first 4 days appeared to be the most associated with outcomes. The segmentation of the data based on intracranial monitoring found limited differences between EVD and IPD, with similar LPRx values around 0.3. CONCLUSION Our work suggests that the underlying prognostic factors causing impairment in cerebrovascular reactivity can, to some degree, be detected using lower resolution PRx metrics (similar found thresholding values) with LPRx found clinically using as low as 10 min-by-minute samples of MAP and ICP. Furthermore, EVD derived LPRx with intermittent cerebrospinal fluid draining, seems to present similar outcome capacity as IPD. This low-resolution low sample LPRx method appears to be an adequate substitute for the clinical prognostic value of PRx and may be implemented independent of ICP monitoring method when PRx is not feasible, though further research is warranted.
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Affiliation(s)
- Erik Hong
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Logan Froese
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.
| | - Emeli Pontén
- Department of Molecular Medicine and Surgery (MMK), Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Skåne University Hospital, Lund, Sweden
| | - Alexander Fletcher-Sandersjöö
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Charles Tatter
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Radiology, Södersjukhuset, Stockholm, Sweden
| | - Emma Hammarlund
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
| | - Cecilia A I Åkerlund
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | | | - Peter Alpkvist
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Jiri Bartek
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki, Helsinki, Finland
| | - Caroline Lindblad
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurosurgery, Uppsala University Hospital, Uppsala, Sweden
- Department of Medical Sciences, Uppsala University, Uppsala, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden
- Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Frederick A Zeiler
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
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Stein KY, Amenta F, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Islam A, Bergmann T, Marquez I, Zeiler FA. Associations Between Intracranial Pressure Extremes and Continuous Metrics of Cerebrovascular Pressure Reactivity in Acute Traumatic Neural Injury: A Scoping Review. Neurotrauma Rep 2024; 5:483-496. [PMID: 39036433 PMCID: PMC11257139 DOI: 10.1089/neur.2023.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Cerebrovascular pressure reactivity plays a key role in maintaining constant cerebral blood flow. Unfortunately, this mechanism is often impaired in acute traumatic neural injury states, exposing the already injured brain to further pressure-passive insults. While there has been much work on the association between impaired cerebrovascular reactivity following moderate/severe traumatic brain injury (TBI) and worse long-term outcomes, there is yet to be a comprehensive review on the association between cerebrovascular pressure reactivity and intracranial pressure (ICP) extremes. Therefore, we conducted a systematic review of the literature for all studies presenting a quantifiable statistical association between a continuous measure of cerebrovascular pressure reactivity and ICP in a human TBI cohort. The methodology described in the Cochrane Handbook for Systematic Reviews was used. BIOSIS, Cochrane Library, EMBASE, Global Health, MEDLINE, and SCOPUS were all searched from their inceptions to March of 2023 for relevant articles. Full-length original works with a sample size of ≥10 patients with moderate/severe TBI were included in this review. Data were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A total of 16 articles were included in this review. Studies varied in population characteristics and statistical tests used. Five studies looked at transcranial Doppler-based indices and 13 looked at ICP-based indices. All but two studies were able to present a statistically significant association between cerebrovascular pressure reactivity and ICP. Based on the findings of this review, impaired reactivity seems to be associated with elevated ICP and reduced ICP waveform complexity. This relationship may allow for the calculation of patient-specific ICP thresholds, past which cerebrovascular reactivity becomes persistently deranged. However, further work is required to better understand this relationship and improve algorithmic derivation of such individualized ICP thresholds.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Abrar Islam
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Tobias Bergmann
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Izabella Marquez
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
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Stein KY, Froese L, Sekhon M, Griesdale D, Thelin EP, Raj R, Tas J, Aries M, Gallagher C, Bernard F, Gomez A, Kramer AH, Zeiler FA. Intracranial Pressure-Derived Cerebrovascular Reactivity Indices and Their Critical Thresholds: A Canadian High Resolution-Traumatic Brain Injury Validation Study. J Neurotrauma 2024; 41:910-923. [PMID: 37861325 DOI: 10.1089/neu.2023.0374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
Current neurointensive care guidelines recommend intracranial pressure (ICP) and cerebral perfusion pressure (CPP) centered management for moderate-severe traumatic brain injury (TBI) because of their demonstrated associations with patient outcome. Cerebrovascular reactivity metrics, such as the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC index, have also demonstrated significant prognostic capabilities with regard to outcome. However, critical thresholds for cerebrovascular reactivity indices have only been identified in two studies conducted at the same center. In this study, we aim to determine the critical thresholds of these metrics by leveraging a unique multi-center database. The study included a total of 354 patients from the CAnadian High-Resolution TBI (CAHR-TBI) Research Collaborative. Based on 6-month Glasgow Outcome Scores, patients were dichotomized into alive versus dead and favorable versus unfavorable. Chi-square values were then computed for incrementally increasing values of each physiological parameter of interest against outcome. The values that generated the greatest chi-squares for each parameter were considered to be the thresholds with the greatest outcome discriminatory capacity. To confirm that the identified thresholds provide prognostic utility, univariate and multivariable logistical regression analyses were performed adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. Through the chi-square analysis, a lower limit CPP threshold of 60 mm Hg and ICP thresholds of 18 mm Hg and 22 mm Hg were identified for both survival and favorable outcome predictions. For the cerebrovascular reactivity metrics, different thresholds were identified for the two outcome dichotomizations. For survival prediction, thresholds of 0.35, 0.25, and 0 were identified for PRx, PAx, and RAC, respectively. For favorable outcome prediction, thresholds of 0.325, 0.20, and 0.05 were found. Univariate logistical regression analysis demonstrated that the time spent above/below thresholds were associated with outcome. Further, multivariable logistical regression analysis found that percent time above/below the identified thresholds added additional variance to the IMPACT core model for predicting both survival and favorable outcome. In this study, we were able to validate the results of the previous two works as well as to reaffirm the ICP and CPP guidelines from the Brain Trauma Foundation (BTF) and the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC).
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mypinder Sekhon
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andreas H Kramer
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Gomez A, Froese L, Griesdale D, Thelin EP, Raj R, van Iperenburg L, Tas J, Aries M, Stein KY, Gallagher C, Bernard F, Kramer AH, Zeiler FA. Prognostic value of near-infrared spectroscopy regional oxygen saturation and cerebrovascular reactivity index in acute traumatic neural injury: a CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Cohort Study. Crit Care 2024; 28:78. [PMID: 38486211 PMCID: PMC10938687 DOI: 10.1186/s13054-024-04859-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2023] [Accepted: 03/02/2024] [Indexed: 03/18/2024] Open
Abstract
BACKGROUND Near-infrared spectroscopy regional cerebral oxygen saturation (rSO2) has gained interest as a raw parameter and as a basis for measuring cerebrovascular reactivity (CVR) due to its noninvasive nature and high spatial resolution. However, the prognostic utility of these parameters has not yet been determined. This study aimed to identify threshold values of rSO2 and rSO2-based CVR at which outcomes worsened following traumatic brain injury (TBI). METHODS A retrospective multi-institutional cohort study was performed. The cohort included TBI patients treated in four adult intensive care units (ICU). The cerebral oxygen indices, COx (using rSO2 and cerebral perfusion pressure) as well as COx_a (using rSO2 and arterial blood pressure) were calculated for each patient. Grand mean thresholds along with exposure-based thresholds were determined utilizing sequential chi-squared analysis and univariate logistic regression, respectively. RESULTS In the cohort of 129 patients, there was no identifiable threshold for raw rSO2 at which outcomes were found to worsen. For both COx and COx_a, an optimal grand mean threshold value of 0.2 was identified for both survival and favorable outcomes, while percent time above - 0.05 was uniformly found to have the best discriminative value. CONCLUSIONS In this multi-institutional cohort study, raw rSO2was found to contain no significant prognostic information. However, rSO2-based indices of CVR, COx and COx_a, were found to have a uniform grand mean threshold of 0.2 and exposure-based threshold of - 0.05, above which clinical outcomes markedly worsened. This study lays the groundwork to transition to less invasive means of continuously measuring CVR.
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Affiliation(s)
- Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
| | - Logan Froese
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology and Therapeutics, University of British Columbia, Vancouver, BC, Canada
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Levi van Iperenburg
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Kevin Y Stein
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Clare Gallagher
- Section of Neurosurgery, Department of Clinical Neurosciences, Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, QC, Canada
| | - Andreas H Kramer
- Department of Clinical Neurosciences, University of Calgary, Calgary, AB, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, AB, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, AB, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Centre on Aging, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Lenell S, Wettervik TS, Howells T, Hånell A, Lewén A, Enblad P. Cerebrovascular reactivity (PRx) and optimal cerebral perfusion pressure in elderly with traumatic brain injury. Acta Neurochir (Wien) 2024; 166:62. [PMID: 38305993 PMCID: PMC10837240 DOI: 10.1007/s00701-024-05956-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2023] [Accepted: 12/23/2023] [Indexed: 02/03/2024]
Abstract
PURPOSE Cerebral perfusion pressure (CPP) guidance by cerebral pressure autoregulation (CPA) status according to PRx (correlation mean arterial blood pressure (MAP) and intracranial pressure (ICP)) and optimal CPP (CPPopt = CPP with lowest PRx) is promising but little is known regarding this approach in elderly. The aim was to analyze PRx and CPPopt in elderly TBI patients. METHODS A total of 129 old (≥ 65 years) and 342 young (16-64 years) patients were studied using monitoring data for MAP and ICP. CPP, PRx, CPPopt, and ΔCPPopt (difference between actual CPP and CPPopt) were calculated. Logistic regression analyses with PRx and ΔCPPopt as explanatory variables for outcome. The combined effects of PRx/CPP and PRx/ΔCPPopt on outcome were visualized as heatmaps. RESULTS The elderly had higher PRx (worse CPA), higher CPPopt, and different temporal patterns. High PRx influenced outcome negatively in the elderly but less so than in younger patients. CPP close to CPPopt correlated to favorable outcome in younger, in contrast to elderly patients. Heatmap interaction analysis of PRx/ΔCPPopt in the elderly showed that the region for favorable outcome was centered around PRx 0 and ranging between both functioning and impaired CPA (PRx range - 0.5-0.5), and the center of ΔCPPopt was - 10 (range - 20-0), while in younger the center of PRx was around - 0.5 and ΔCPPopt closer to zero. CONCLUSIONS The elderly exhibit higher PRx and CPPopt. High PRx influences outcome negatively in the elderly but less than in younger patients. The elderly do not show better outcome when CPP is close to CPPopt in contrast to younger patients.
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Affiliation(s)
- Samuel Lenell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden.
| | - Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University Hospital, Uppsala University, 751 85, Uppsala, Sweden
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Risinger Liljegren A, Brorsson C, Karlsson M, Koskinen LOD, Sundström N. Cerebrovascular Pressure Reactivity Measures: Index Comparison and Clinical Outcome in Patients With Traumatic Brain Injury Treated According to an Intracranial Pressure-Focused Management: Rejection of the Null Hypothesis. Neurotrauma Rep 2023; 4:848-856. [PMID: 38156075 PMCID: PMC10754344 DOI: 10.1089/neur.2023.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
The aim was to investigate whether the pressure reactivity indices PRx, long-PRx (L-PRx), and pressure reactivity (PR) are interchangeable as measures of vascular reactivity, and whether they correlate with clinical outcome when an intracranial pressure (ICP)-targeted treatment regimen is applied in patients with traumatic brain injury (TBI). Patients with TBI (n = 29) that arrived at the hospital within 24 h of injury were included. PRx and L-PRx were derived from Pearson correlations between mean arterial pressure (MAP) and ICP over a short- and long-time interval. PR was the regression coefficient between the hourly mean values of ICP and MAP. Indices were compared to each other, parameters at admission, and outcome assessed by the extended Glasgow Outcome Scale-Extended (GOSE) at 6 and 12 months. PRx and L-PRx had the strongest correlation with each other (R = 0.536, p < 0.01). A correlation was also noted between L-PRx and PR (R = 0.475, p < 0.01), but not between PRx and PR. A correlation was found between age and PRx (R = 0.482, p = 0.01). No association with outcome for any of the indices was found. PRx/L-PRx and L-PRx/PR were moderately correlated with each other. Age was associated with PRx. None of the indices correlated with outcome when our ICP treatment regime was applied. Part of our null hypothesis, that the three indices are associated with outcome, must be rejected. There was, however, an association between some of the indices. To further understand the relation of treatment regimes and pressure reactivity indices, a larger, randomized study is warranted.
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Affiliation(s)
- Axel Risinger Liljegren
- Department of Clinical Science-Neurosciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Camilla Brorsson
- Department of Surgery and Perioperative Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Marcus Karlsson
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Lars-Owe D. Koskinen
- Department of Clinical Science-Neurosciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Islam A, Marquez I, Amenta F, Bergmann T, Zeiler FA. Time spent above optimal cerebral perfusion pressure is not associated with failure to improve in outcome in traumatic brain injury. Intensive Care Med Exp 2023; 11:92. [PMID: 38095819 PMCID: PMC10721751 DOI: 10.1186/s40635-023-00579-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/09/2023] [Accepted: 12/07/2023] [Indexed: 12/17/2023] Open
Abstract
BACKGROUND Optimal cerebral perfusion pressure (CPPopt) has emerged as a promising personalized medicine approach to the management of moderate-to-severe traumatic brain injury (TBI). Though literature demonstrating its association with poor outcomes exists, there is yet to be work done on its association with outcome transition due to a lack of serial outcome data analysis. In this study we investigate the association between various metrics of CPPopt and failure to improve in outcome over time. METHODS CPPopt was derived using three different cerebrovascular reactivity indices; the pressure reactivity index (PRx), the pulse amplitude index (PAx), and the RAC index. For each index, % times spent with cerebral perfusion pressure (CPP) above and below its CPPopt and upper and lower limits of reactivity were calculated. Patients were dichotomized based on improvement in Glasgow Outcome Scale-Extended (GOSE) scores into Improved vs. Not Improved between 1 and 3 months, 3 and 6 months, and 1- and 6-month post-TBI. Logistic regression analyses were then conducted, adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. RESULTS This study included a total of 103 patients from the Winnipeg Acute TBI Database. Through Mann-Whitney U testing and logistic regression analysis, it was found that % time spent with CPP below CPPopt was associated with failure to improve in outcome, while % time spent with CPP above CPPopt was generally associated with improvement in outcome. CONCLUSIONS Our study supports the existing narrative that time spent with CPP below CPPopt results in poorer outcomes. However, it also suggests that time spent above CPPopt may not be associated with worse outcomes and is possibly even associated with improvement in outcome.
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Abrar Islam
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Izabella Marquez
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Tobias Bergmann
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
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10
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Cucciolini G, Motroni V, Czosnyka M. Intracranial pressure for clinicians: it is not just a number. JOURNAL OF ANESTHESIA, ANALGESIA AND CRITICAL CARE 2023; 3:31. [PMID: 37670387 PMCID: PMC10481563 DOI: 10.1186/s44158-023-00115-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Accepted: 08/16/2023] [Indexed: 09/07/2023]
Abstract
BACKGROUND Invasive intracranial pressure (ICP) monitoring is a standard practice in severe brain injury cases, where it allows to derive cerebral perfusion pressure (CPP); ICP-tracing can also provide additional information about intracranial dynamics, forecast episodes of intracranial hypertension and set targets for a tailored therapy to prevent secondary brain injury. Nevertheless, controversies about the advantages of an ICP clinical management are still debated. FINDINGS This article reviews recent research on ICP to improve the understanding of the topic and uncover the hidden information in this signal that may be useful in clinical practice. Parameters derived from time-domain as well as frequency domain analysis include compensatory reserve, autoregulation estimation, pulse waveform analysis, and behavior of ICP in time. The possibility to predict the outcome and apply a tailored therapy using a personalised perfusion pressure target is also described. CONCLUSIONS ICP is a crucial signal to monitor in severely brain injured patients; a bedside computer can empower standard monitoring giving new metrics that may aid in clinical management, establish a personalized therapy, and help to predict the outcome. Continuous collaboration between engineers and clinicians and application of new technologies to healthcare, is vital to improve the accuracy of current metrics and progress towards better care with individualized dynamic targets.
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Affiliation(s)
- Giada Cucciolini
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy.
- Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, University of Cambridge, Cambridge, UK.
| | - Virginia Motroni
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Pisa, Italy
- Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Division of Neurosurgery, Brain Physics Laboratory, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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11
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Rajagopalan S, Sarwal A. The authors reply. Crit Care Med 2023; 51:e191-e192. [PMID: 37589529 DOI: 10.1097/ccm.0000000000005958] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/18/2023]
Affiliation(s)
- Swarna Rajagopalan
- Department of Neurology, Cooper Medical School of Rowan University, Camden, NJ
| | - Aarti Sarwal
- Department of Neurology, Wake Forest University School of Medicine, Winston Salem, NC
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12
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Svedung Wettervik T, Beqiri E, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury: part I-To what extent does PbtO 2 reflect global cerebral physiology? Crit Care 2023; 27:339. [PMID: 37653526 PMCID: PMC10472704 DOI: 10.1186/s13054-023-04627-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The primary aim was to explore the association of global cerebral physiological variables including intracranial pressure (ICP), cerebrovascular reactivity (PRx), cerebral perfusion pressure (CPP), and deviation from the PRx-based optimal CPP value (∆CPPopt; actual CPP-CPPopt) in relation to brain tissue oxygenation (pbtO2) in traumatic brain injury (TBI). METHODS A total of 425 TBI patients with ICP- and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Generalized additive models (GAMs) and linear mixed effect models were used to explore the association of ICP, PRx, CPP, and CPPopt in relation to pbtO2. PbtO2 < 20 mmHg, ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, and ∆CPPopt < - 5 mmHg were considered as cerebral insults. RESULTS PbtO2 < 20 mmHg occurred in median during 17% of the monitoring time and in less than 5% in combination with ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, or ∆CPPopt < - 5 mmHg. In GAM analyses, pbtO2 remained around 25 mmHg over a large range of ICP ([0;50] mmHg) and PRx [- 1;1], but deteriorated below 20 mmHg for extremely low CPP below 30 mmHg and ∆CPPopt below - 30 mmHg. In linear mixed effect models, ICP, CPP, PRx, and ∆CPPopt were significantly associated with pbtO2, but the fixed effects could only explain a very small extent of the pbtO2 variation. CONCLUSIONS PbtO2 below 20 mmHg was relatively frequent and often occurred in the absence of disturbances in ICP, PRx, CPP, and ∆CPPopt. There were significant, but weak associations between the global cerebral physiological variables and pbtO2, suggesting that hypoxic pbtO2 is often a complex and independent pathophysiological event. Thus, other variables may be more crucial to explain pbtO2 and, likewise, pbtO2 may not be a suitable outcome measure to determine whether global cerebral blood flow optimization such as CPPopt therapy is successful.
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Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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14
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Stein KY, Amenta F, Gomez A, Froese L, Sainbhi AS, Vakitbilir N, Marquez I, Zeiler FA. Associations between intracranial pressure thresholds and multimodal monitoring in acute traumatic neural injury: a scoping review. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05587-6. [PMID: 37067617 DOI: 10.1007/s00701-023-05587-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Current moderate/severe traumatic brain injury (TBI) guidelines suggest the use of an intracranial pressure (ICP) treatment threshold of 20 mmHg or 22 mmHg. Over the past decade, the use of various cerebral physiology monitoring devices has been incorporated into neurocritical care practice and termed "multimodal monitoring." Such modalities include those that monitor systemic hemodynamics, systemic and brain oxygenation, cerebral blood flow (CBF), cerebral autoregulation, electrophysiology, and cerebral metabolism. Given that the relationship between ICP and outcomes is not yet entirely understood, a comprehensive review of the literature on the associations between ICP thresholds and multimodal monitoring is still needed. METHODS We conducted a scoping review of the literature for studies that present an objective statistical association between ICP above/below threshold and any multimodal monitoring variable. MEDLINE, BIOSIS, Cochrane library, EMBASE, Global Health, and SCOPUS were searched from inception to July 2022 for relevant articles. Full-length, peer-reviewed, original works with a sample size of ≥50 moderate-severe TBI patients were included in this study. RESULTS A total of 13 articles were deemed eligible for final inclusion. The included articles were significantly heterogenous in terms of their designs, demographics, and results, making it difficult to draw any definitive conclusions. No literature describing the association between guideline-based ICP thresholds and measures of brain electrophysiology, cerebral metabolism, or direct metrics of CBF was found. CONCLUSION There is currently little literature that presents objective statistical associations between ICP thresholds and multimodal monitoring physiology. However, overall, the literature indicates that having ICP above guideline based thresholds is associated with increased blood pressure, increased cardiac decoupling, reduced parenchymal brain oxygen tension, and impaired cerebral autoregulation, with no association with CBF velocity within the therapeutic range of ICP. There was insufficient literature to comment on other multimodal monitoring measures.
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Fiorella Amenta
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Izabella Marquez
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Centre on Aging, University of Manitoba, Winnipeg, Canada
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Denchev K, Gomez J, Chen P, Rosenblatt K. Traumatic Brain Injury: Intraoperative Management and Intensive Care Unit Multimodality Monitoring. Anesthesiol Clin 2023; 41:39-78. [PMID: 36872007 DOI: 10.1016/j.anclin.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Traumatic brain injury is a devastating event associated with substantial morbidity. Pathophysiology involves the initial trauma, subsequent inflammatory response, and secondary insults, which worsen brain injury severity. Management entails cardiopulmonary stabilization and diagnostic imaging with targeted interventions, such as decompressive hemicraniectomy, intracranial monitors or drains, and pharmacological agents to reduce intracranial pressure. Anesthesia and intensive care requires control of multiple physiologic variables and evidence-based practices to reduce secondary brain injury. Advances in biomedical engineering have enhanced assessments of cerebral oxygenation, pressure, metabolism, blood flow, and autoregulation. Many centers employ multimodality neuromonitoring for targeted therapies with the hope to improve recovery.
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Affiliation(s)
- Krassimir Denchev
- Department of Anesthesiology, Wayne State University, 44555 Woodward Avenue, SJMO Medical Office Building, Suite 308, Pontiac, MI 48341, USA
| | - Jonathan Gomez
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA
| | - Pinxia Chen
- Department of Anesthesiology and Critical Care Medicine, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA; Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA.
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Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Marquez I, Amenta F, Park K, Stein KY, Thelin EP, Zeiler FA. Cerebrovascular Reactivity Is Not Associated With Therapeutic Intensity in Adult Traumatic Brain Injury: A Validation Study. Neurotrauma Rep 2023; 4:307-317. [PMID: 37187506 PMCID: PMC10181802 DOI: 10.1089/neur.2023.0011] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/17/2023] Open
Abstract
Within traumatic brain injury (TBI) care, there is growing interest in pathophysiological markers as surrogates of disease severity, which may be used to improve and individualize care. Of these, assessment of cerebrovascular reactivity (CVR) has been extensively studied given that it is a consistent, independent factor associated with mortality and functional outcome. However, to date, the literature supports little-to-no impact of current guideline-supported therapeutic interventions on continuously measured CVR. Previous work in this area has suffered from a lack of validation studies, given the rarity of time-matched high-frequency cerebral physiology with serially recorded therapeutic interventions; thus, we undertook a validation study. Utilizing the Winnipeg Acute TBI database, we evaluated the association between daily treatment intensity levels, as measured through the therapeutic intensity level (TIL) scoring system, and continuous multi-modal-derived CVR measures. CVR measures included the intracranial pressure (ICP)-derived pressure reactivity index, pulse amplitude index, and RAC index (a correlation between the pulse amplitude of ICP and cerebral perfusion pressure), as well as the cerebral autoregulation measure of near-infrared spectroscopy-based cerebral oximetry index. These measures were also derived over a key threshold for each day and were compared to the daily total TIL measure. In summary, we could not observe any overall relationship between TIL and these CVR measures. This validates previous findings and represents only the second such analysis to date. This helps to confirm that CVR appears to remain independent of current therapeutic interventions and is a potential unique physiological target for critical care. Further work into the high-frequency relationship between critical care and CVR is required.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Address correspondence to: Logan Froese, BSc (Eng), Biomedical Engineering, Faculty of Engineering, University of Manitoba, 75 Chancellor's Circle, Winnipeg, Manitoba R3T 5V6, Canada;
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Izzy Marquez
- Undergraduate Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kangyun Park
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Eric P. Thelin
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Frederick A. Zeiler
- Biomedical Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Gomez A, Sekhon M, Griesdale D, Froese L, Yang E, Thelin EP, Raj R, Aries M, Gallagher C, Bernard F, Kramer AH, Zeiler FA. Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study. Intensive Care Med Exp 2022; 10:54. [PMID: 36550386 PMCID: PMC9780411 DOI: 10.1186/s40635-022-00482-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Brain tissue oxygen tension (PbtO2) and cerebrovascular pressure reactivity monitoring have emerged as potential modalities to individualize care in moderate and severe traumatic brain injury (TBI). The relationship between these modalities has had limited exploration. The aim of this study was to examine the relationship between PbtO2 and cerebral perfusion pressure (CPP) and how this relationship is modified by the state of cerebrovascular pressure reactivity. METHODS A retrospective multi-institution cohort study utilizing prospectively collected high-resolution physiologic data from the CAnadian High Resolution-TBI (CAHR-TBI) Research Collaborative database collected between 2011 and 2021 was performed. Included in the study were critically ill TBI patients with intracranial pressure (ICP), arterial blood pressure (ABP), and PbtO2 monitoring treated in any one of three CAHR-TBI affiliated adult intensive care units (ICU). The outcome of interest was how PbtO2 and CPP are related over a cohort of TBI patients and how this relationship is modified by the state of cerebrovascular reactivity, as determined using the pressure reactivity index (PRx). RESULTS A total of 77 patients met the study inclusion criteria with a total of 377,744 min of physiologic data available for the analysis. PbtO2 produced a triphasic curve when plotted against CPP like previous population-based plots of cerebral blood flow (CBF) versus CPP. The triphasic curve included a plateau region flanked by regions of relative ischemia (hypoxia) and hyperemia (hyperoxia). The plateau region shortened when cerebrovascular pressure reactivity was disrupted compared to when it was intact. CONCLUSIONS In this exploratory analysis of a multi-institution high-resolution physiology TBI database, PbtO2 seems to have a triphasic relationship with CPP, over the entire cohort. The CPP range over which the plateau exists is modified by the state of cerebrovascular reactivity. This indicates that in critically ill TBI patients admitted to ICU, PbtO2 may be reflective of CBF.
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Affiliation(s)
- Alwyn Gomez
- grid.21613.370000 0004 1936 9609Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ,grid.21613.370000 0004 1936 9609Present Address: Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Mypinder Sekhon
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Present Address: Division of Critical Care, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Donald Griesdale
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada
| | - Logan Froese
- grid.21613.370000 0004 1936 9609Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB Canada
| | - Eleen Yang
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada
| | - Eric P. Thelin
- grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- grid.7737.40000 0004 0410 2071Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marcel Aries
- grid.412966.e0000 0004 0480 1382Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- grid.22072.350000 0004 1936 7697Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Francis Bernard
- grid.14848.310000 0001 2292 3357Section of Critical Care, Department of Medicine, University of Montreal, Montreal, QC Canada
| | - Andreas H. Kramer
- grid.22072.350000 0004 1936 7697Department of Critical Care Medicine, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Frederick A. Zeiler
- grid.21613.370000 0004 1936 9609Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ,grid.21613.370000 0004 1936 9609Present Address: Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada ,grid.21613.370000 0004 1936 9609Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB Canada ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.21613.370000 0004 1936 9609Centre On Aging, University of Manitoba, Winnipeg, Canada ,grid.5335.00000000121885934Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Stein KY, Froese L, Gomez A, Sainbhi AS, Batson C, Mathieu F, Zeiler FA. Association between cerebrovascular reactivity in adult traumatic brain injury and improvement in patient outcome over time: an exploratory analysis. Acta Neurochir (Wien) 2022; 164:3107-3118. [PMID: 36156746 DOI: 10.1007/s00701-022-05366-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Accepted: 09/14/2022] [Indexed: 02/01/2023]
Abstract
BACKGROUND Impaired cerebrovascular reactivity following moderate/severe traumatic brain injury (TBI) has emerged as a key potential driver of morbidity and mortality. However, the major contributions to the literature so far have been solely focused on single point measures of long-term outcome. Therefore, it remains unknown whether cerebrovascular reactivity impairment, during the acute phase of TBI, is associated with failure to improve in outcome across time. METHODS Cerebrovascular reactivity was measured using three intracranial pressure-based surrogate metrics. For each patient, % time spent above various literature-defined thresholds was calculated. Patients were dichotomized based on outcome transition into Improved vs Not Improved between 1 and 3 months, 3 and 6 months, and 1 and 6 months, based on the Glasgow Outcome Scale-Extended (GOSE). Univariate and multivariable logistic regression analyses were performed, adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. RESULTS Seventy-eight patients from the Winnipeg Acute TBI Database were included in this study. On univariate logistic regression analysis, higher % time with cerebrovascular reactivity metrics above clinically defined thresholds was associated with a lack of clinical improvement between 1 and 3 months and 1 and 6 months post injury (p < 0.05). These relationships held true on multivariable logistic regression analysis. CONCLUSION Our study demonstrates that impaired cerebrovascular reactivity, during the acute phase of TBI, is associated with failure to improve clinically over time. These preliminary findings highlight the significance that cerebrovascular reactivity monitoring carries in outcome recovery association in moderate/severe TBI.
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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19
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Maas AIR, Menon DK, Manley GT, Abrams M, Åkerlund C, Andelic N, Aries M, Bashford T, Bell MJ, Bodien YG, Brett BL, Büki A, Chesnut RM, Citerio G, Clark D, Clasby B, Cooper DJ, Czeiter E, Czosnyka M, Dams-O’Connor K, De Keyser V, Diaz-Arrastia R, Ercole A, van Essen TA, Falvey É, Ferguson AR, Figaji A, Fitzgerald M, Foreman B, Gantner D, Gao G, Giacino J, Gravesteijn B, Guiza F, Gupta D, Gurnell M, Haagsma JA, Hammond FM, Hawryluk G, Hutchinson P, van der Jagt M, Jain S, Jain S, Jiang JY, Kent H, Kolias A, Kompanje EJO, Lecky F, Lingsma HF, Maegele M, Majdan M, Markowitz A, McCrea M, Meyfroidt G, Mikolić A, Mondello S, Mukherjee P, Nelson D, Nelson LD, Newcombe V, Okonkwo D, Orešič M, Peul W, Pisică D, Polinder S, Ponsford J, Puybasset L, Raj R, Robba C, Røe C, Rosand J, Schueler P, Sharp DJ, Smielewski P, Stein MB, von Steinbüchel N, Stewart W, Steyerberg EW, Stocchetti N, Temkin N, Tenovuo O, Theadom A, Thomas I, Espin AT, Turgeon AF, Unterberg A, Van Praag D, van Veen E, Verheyden J, Vyvere TV, Wang KKW, Wiegers EJA, Williams WH, Wilson L, Wisniewski SR, Younsi A, Yue JK, Yuh EL, Zeiler FA, Zeldovich M, Zemek R. Traumatic brain injury: progress and challenges in prevention, clinical care, and research. Lancet Neurol 2022; 21:1004-1060. [PMID: 36183712 PMCID: PMC10427240 DOI: 10.1016/s1474-4422(22)00309-x] [Citation(s) in RCA: 250] [Impact Index Per Article: 125.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2022] [Accepted: 07/22/2022] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) has the highest incidence of all common neurological disorders, and poses a substantial public health burden. TBI is increasingly documented not only as an acute condition but also as a chronic disease with long-term consequences, including an increased risk of late-onset neurodegeneration. The first Lancet Neurology Commission on TBI, published in 2017, called for a concerted effort to tackle the global health problem posed by TBI. Since then, funding agencies have supported research both in high-income countries (HICs) and in low-income and middle-income countries (LMICs). In November 2020, the World Health Assembly, the decision-making body of WHO, passed resolution WHA73.10 for global actions on epilepsy and other neurological disorders, and WHO launched the Decade for Action on Road Safety plan in 2021. New knowledge has been generated by large observational studies, including those conducted under the umbrella of the International Traumatic Brain Injury Research (InTBIR) initiative, established as a collaboration of funding agencies in 2011. InTBIR has also provided a huge stimulus to collaborative research in TBI and has facilitated participation of global partners. The return on investment has been high, but many needs of patients with TBI remain unaddressed. This update to the 2017 Commission presents advances and discusses persisting and new challenges in prevention, clinical care, and research. In LMICs, the occurrence of TBI is driven by road traffic incidents, often involving vulnerable road users such as motorcyclists and pedestrians. In HICs, most TBI is caused by falls, particularly in older people (aged ≥65 years), who often have comorbidities. Risk factors such as frailty and alcohol misuse provide opportunities for targeted prevention actions. Little evidence exists to inform treatment of older patients, who have been commonly excluded from past clinical trials—consequently, appropriate evidence is urgently required. Although increasing age is associated with worse outcomes from TBI, age should not dictate limitations in therapy. However, patients injured by low-energy falls (who are mostly older people) are about 50% less likely to receive critical care or emergency interventions, compared with those injured by high-energy mechanisms, such as road traffic incidents. Mild TBI, defined as a Glasgow Coma sum score of 13–15, comprises most of the TBI cases (over 90%) presenting to hospital. Around 50% of adult patients with mild TBI presenting to hospital do not recover to pre-TBI levels of health by 6 months after their injury. Fewer than 10% of patients discharged after presenting to an emergency department for TBI in Europe currently receive follow-up. Structured follow-up after mild TBI should be considered good practice, and urgent research is needed to identify which patients with mild TBI are at risk for incomplete recovery. The selection of patients for CT is an important triage decision in mild TBI since it allows early identification of lesions that can trigger hospital admission or life-saving surgery. Current decision making for deciding on CT is inefficient, with 90–95% of scanned patients showing no intracranial injury but being subjected to radiation risks. InTBIR studies have shown that measurement of blood-based biomarkers adds value to previously proposed clinical decision rules, holding the potential to improve efficiency while reducing radiation exposure. Increased concentrations of biomarkers in the blood of patients with a normal presentation CT scan suggest structural brain damage, which is seen on MR scanning in up to 30% of patients with mild TBI. Advanced MRI, including diffusion tensor imaging and volumetric analyses, can identify additional injuries not detectable by visual inspection of standard clinical MR images. Thus, the absence of CT abnormalities does not exclude structural damage—an observation relevant to litigation procedures, to management of mild TBI, and when CT scans are insufficient to explain the severity of the clinical condition. Although blood-based protein biomarkers have been shown to have important roles in the evaluation of TBI, most available assays are for research use only. To date, there is only one vendor of such assays with regulatory clearance in Europe and the USA with an indication to rule out the need for CT imaging for patients with suspected TBI. Regulatory clearance is provided for a combination of biomarkers, although evidence is accumulating that a single biomarker can perform as well as a combination. Additional biomarkers and more clinical-use platforms are on the horizon, but cross-platform harmonisation of results is needed. Health-care efficiency would benefit from diversity in providers. In the intensive care setting, automated analysis of blood pressure and intracranial pressure with calculation of derived parameters can help individualise management of TBI. Interest in the identification of subgroups of patients who might benefit more from some specific therapeutic approaches than others represents a welcome shift towards precision medicine. Comparative-effectiveness research to identify best practice has delivered on expectations for providing evidence in support of best practices, both in adult and paediatric patients with TBI. Progress has also been made in improving outcome assessment after TBI. Key instruments have been translated into up to 20 languages and linguistically validated, and are now internationally available for clinical and research use. TBI affects multiple domains of functioning, and outcomes are affected by personal characteristics and life-course events, consistent with a multifactorial bio-psycho-socio-ecological model of TBI, as presented in the US National Academies of Sciences, Engineering, and Medicine (NASEM) 2022 report. Multidimensional assessment is desirable and might be best based on measurement of global functional impairment. More work is required to develop and implement recommendations for multidimensional assessment. Prediction of outcome is relevant to patients and their families, and can facilitate the benchmarking of quality of care. InTBIR studies have identified new building blocks (eg, blood biomarkers and quantitative CT analysis) to refine existing prognostic models. Further improvement in prognostication could come from MRI, genetics, and the integration of dynamic changes in patient status after presentation. Neurotrauma researchers traditionally seek translation of their research findings through publications, clinical guidelines, and industry collaborations. However, to effectively impact clinical care and outcome, interactions are also needed with research funders, regulators, and policy makers, and partnership with patient organisations. Such interactions are increasingly taking place, with exemplars including interactions with the All Party Parliamentary Group on Acquired Brain Injury in the UK, the production of the NASEM report in the USA, and interactions with the US Food and Drug Administration. More interactions should be encouraged, and future discussions with regulators should include debates around consent from patients with acute mental incapacity and data sharing. Data sharing is strongly advocated by funding agencies. From January 2023, the US National Institutes of Health will require upload of research data into public repositories, but the EU requires data controllers to safeguard data security and privacy regulation. The tension between open data-sharing and adherence to privacy regulation could be resolved by cross-dataset analyses on federated platforms, with the data remaining at their original safe location. Tools already exist for conventional statistical analyses on federated platforms, however federated machine learning requires further development. Support for further development of federated platforms, and neuroinformatics more generally, should be a priority. This update to the 2017 Commission presents new insights and challenges across a range of topics around TBI: epidemiology and prevention (section 1 ); system of care (section 2 ); clinical management (section 3 ); characterisation of TBI (section 4 ); outcome assessment (section 5 ); prognosis (Section 6 ); and new directions for acquiring and implementing evidence (section 7 ). Table 1 summarises key messages from this Commission and proposes recommendations for the way forward to advance research and clinical management of TBI.
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Affiliation(s)
- Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Geoffrey T Manley
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Mathew Abrams
- International Neuroinformatics Coordinating Facility, Karolinska Institutet, Stockholm, Sweden
| | - Cecilia Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Nada Andelic
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tom Bashford
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Michael J Bell
- Critical Care Medicine, Neurological Surgery and Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Yelena G Bodien
- Department of Neurology and Department of Physical Medicine and Rehabilitation, Harvard Medical School, Boston, MA, USA
| | - Benjamin L Brett
- Department of Neurosurgery, Medical College of Wisconsin, Milwaukee, WI, USA
| | - András Büki
- Department of Neurosurgery, Faculty of Medicine and Health Örebro University, Örebro, Sweden
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Randall M Chesnut
- Department of Neurological Surgery and Department of Orthopaedics and Sports Medicine, University of Washington, Harborview Medical Center, Seattle, WA, USA
| | - Giuseppe Citerio
- School of Medicine and Surgery, Universita Milano Bicocca, Milan, Italy
- NeuroIntensive Care, San Gerardo Hospital, Azienda Socio Sanitaria Territoriale (ASST) Monza, Monza, Italy
| | - David Clark
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Betony Clasby
- Department of Sociological Studies, University of Sheffield, Sheffield, UK
| | - D Jamie Cooper
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Endre Czeiter
- Department of Neurosurgery, Medical School; ELKH-PTE Clinical Neuroscience MR Research Group; and Neurotrauma Research Group, Janos Szentagothai Research Centre, University of Pecs, Pecs, Hungary
| | - Marek Czosnyka
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Kristen Dams-O’Connor
- Department of Rehabilitation and Human Performance and Department of Neurology, Brain Injury Research Center, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Véronique De Keyser
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Ramon Diaz-Arrastia
- Department of Neurology and Center for Brain Injury and Repair, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA, USA
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Thomas A van Essen
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
- Department of Neurosurgery, Medical Center Haaglanden, The Hague, Netherlands
| | - Éanna Falvey
- College of Medicine and Health, University College Cork, Cork, Ireland
| | - Adam R Ferguson
- Brain and Spinal Injury Center, Department of Neurological Surgery, Weill Institute for Neurosciences, University of California San Francisco and San Francisco Veterans Affairs Healthcare System, San Francisco, CA, USA
| | - Anthony Figaji
- Division of Neurosurgery and Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Melinda Fitzgerald
- Curtin Health Innovation Research Institute, Curtin University, Bentley, WA, Australia
- Perron Institute for Neurological and Translational Sciences, Nedlands, WA, Australia
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Dashiell Gantner
- School of Public Health and Preventive Medicine, Monash University and The Alfred Hospital, Melbourne, VIC, Australia
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiaotong University School of Medicine
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Harvard Medical School and Spaulding Rehabilitation Hospital, Charlestown, MA, USA
| | - Benjamin Gravesteijn
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fabian Guiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Deepak Gupta
- Department of Neurosurgery, Neurosciences Centre and JPN Apex Trauma Centre, All India Institute of Medical Sciences, New Delhi, India
| | - Mark Gurnell
- Metabolic Research Laboratories, Institute of Metabolic Science, University of Cambridge, Cambridge, UK
| | - Juanita A Haagsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Flora M Hammond
- Department of Physical Medicine and Rehabilitation, Indiana University School of Medicine, Rehabilitation Hospital of Indiana, Indianapolis, IN, USA
| | - Gregory Hawryluk
- Section of Neurosurgery, GB1, Health Sciences Centre, University of Manitoba, Winnipeg, MB, Canada
| | - Peter Hutchinson
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Mathieu van der Jagt
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health, University of California, San Diego, CA, USA
| | - Swati Jain
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Ji-yao Jiang
- Department of Neurosurgery, Shanghai Renji Hospital, Shanghai Jiaotong University School of Medicine, Shanghai, China
| | - Hope Kent
- Department of Psychology, University of Exeter, Exeter, UK
| | - Angelos Kolias
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Erwin J O Kompanje
- Department of Intensive Care, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Fiona Lecky
- Centre for Urgent and Emergency Care Research, Health Services Research Section, School of Health and Related Research, University of Sheffield, Sheffield, UK
| | - Hester F Lingsma
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Marc Maegele
- Cologne-Merheim Medical Center, Department of Trauma and Orthopedic Surgery, Witten/Herdecke University, Cologne, Germany
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Faculty of Health Sciences and Social Work, Trnava University, Trnava, Slovakia
| | - Amy Markowitz
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Michael McCrea
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Ana Mikolić
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Stefania Mondello
- Department of Biomedical and Dental Sciences and Morphofunctional Imaging, University of Messina, Messina, Italy
| | - Pratik Mukherjee
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - David Nelson
- Section for Anesthesiology and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Lindsay D Nelson
- Department of Neurosurgery and Neurology, Medical College of Wisconsin, Milwaukee, WI, USA
| | - Virginia Newcombe
- Division of Anaesthesia, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - David Okonkwo
- Department of Neurological Surgery, University of Pittsburgh, Pittsburgh, PA, USA
| | - Matej Orešič
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Wilco Peul
- Department of Neurosurgery, Leiden University Medical Center, Leiden, Netherlands
| | - Dana Pisică
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
- Department of Neurosurgery, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Suzanne Polinder
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - Jennie Ponsford
- Monash-Epworth Rehabilitation Research Centre, Turner Institute for Brain and Mental Health, School of Psychological Sciences, Monash University, Melbourne, VIC, Australia
| | - Louis Puybasset
- Department of Anesthesiology and Intensive Care, APHP, Sorbonne Université, Hôpital Pitié-Salpêtrière, Paris, France
| | - Rahul Raj
- Department of Neurosurgery, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
| | - Chiara Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino IRCCS for Oncology and Neuroscience, Genova, Italy, and Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Italy
| | - Cecilie Røe
- Division of Clinical Neuroscience, Department of Physical Medicine and Rehabilitation, Oslo University Hospital and University of Oslo, Oslo, Norway
| | - Jonathan Rosand
- Center for Genomic Medicine, Massachusetts General Hospital, Boston, MA, USA
| | | | - David J Sharp
- Department of Brain Sciences, Imperial College London, London, UK
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke’s Hospital, Cambridge, UK
| | - Murray B Stein
- Department of Psychiatry and Department of Family Medicine and Public Health, UCSD School of Medicine, La Jolla, CA, USA
| | - Nicole von Steinbüchel
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - William Stewart
- Department of Neuropathology, Queen Elizabeth University Hospital and University of Glasgow, Glasgow, UK
| | - Ewout W Steyerberg
- Department of Biomedical Data Sciences Leiden University Medical Center, Leiden, Netherlands
| | - Nino Stocchetti
- Department of Pathophysiology and Transplantation, Milan University, and Neuroscience ICU, Fondazione IRCCS Ca Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nancy Temkin
- Departments of Neurological Surgery, and Biostatistics, University of Washington, Seattle, WA, USA
| | - Olli Tenovuo
- Department of Rehabilitation and Brain Trauma, Turku University Hospital, and Department of Neurology, University of Turku, Turku, Finland
| | - Alice Theadom
- National Institute for Stroke and Applied Neurosciences, Faculty of Health and Environmental Studies, Auckland University of Technology, Auckland, New Zealand
| | - Ilias Thomas
- School of Medical Sciences, Örebro University, Örebro, Sweden
| | - Abel Torres Espin
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Alexis F Turgeon
- Department of Anesthesiology and Critical Care Medicine, Division of Critical Care Medicine, Université Laval, CHU de Québec-Université Laval Research Center, Québec City, QC, Canada
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - Dominique Van Praag
- Departments of Clinical Psychology and Neurosurgery, Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Ernest van Veen
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | | | - Thijs Vande Vyvere
- Department of Radiology, Faculty of Medicine and Health Sciences, Department of Rehabilitation Sciences (MOVANT), Antwerp University Hospital, and University of Antwerp, Edegem, Belgium
| | - Kevin K W Wang
- Department of Psychiatry, University of Florida, Gainesville, FL, USA
| | - Eveline J A Wiegers
- Department of Public Health, Erasmus MC University Medical Center Rotterdam, Rotterdam, Netherlands
| | - W Huw Williams
- Centre for Clinical Neuropsychology Research, Department of Psychology, University of Exeter, Exeter, UK
| | - Lindsay Wilson
- Division of Psychology, University of Stirling, Stirling, UK
| | - Stephen R Wisniewski
- University of Pittsburgh Graduate School of Public Health, Pittsburgh, Pennsylvania, USA
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, Heidelberg, Germany
| | - John K Yue
- Department of Neurological Surgery, University of California, San Francisco, CA, USA
| | - Esther L Yuh
- Department of Radiology and Biomedical Imaging, University of California San Francisco, San Francisco, CA, USA
| | - Frederick A Zeiler
- Departments of Surgery, Human Anatomy and Cell Science, and Biomedical Engineering, Rady Faculty of Health Sciences and Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Marina Zeldovich
- Institute of Medical Psychology and Medical Sociology, University Medical Center Goettingen, Goettingen, Germany
| | - Roger Zemek
- Departments of Pediatrics and Emergency Medicine, University of Ottawa, Children’s Hospital of Eastern Ontario, ON, Canada
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20
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Batson C, Froese L, Sekhon MS, Griesdale DE, Gomez A, Thelin EP, Raj R, Aries M, Gallagher CN, Bernard F, Kramer AH, Zeiler FA. Impact of Chronological Age and Biological Sex on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A CAnadian High-Resolution TBI (CAHR-TBI) Study. J Neurotrauma 2022. [PMID: 36047825 DOI: 10.1089/neu.2022.0293] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Impaired cerebrovascular reactivity has emerged as an important associate with poor long-term outcome after moderate/severe traumatic brain injury (TBI). However, our understanding of what drives or modulates the degree of impaired cerebrovascular function remains poor. Age and biological sex remain important modifiers of cerebrovascular function in health and disease, yet their impact on cerebrovascular reactivity after TBI remains unclear. The aim of this study was to explore subgroup responses based on age and biological sex on cerebral physiology. Data from 283 TBI patients from the CAnadian High Resolution TBI (CAHR-TBI) Research Collaborative were evaluated. Cerebrovascular reactivity was determined using high-frequency cerebral physiology for the derivation of three intracranial pressure (ICP) based indices: (1). PRx - correlation between ICP and mean arterial pressure (MAP), (2). PAx - correlation between pulse amplitude of ICP (AMP) and MAP and (3). RAC - correlation between AMP and cerebral perfusion pressure (CPP). Insult burden (% time above clinically defined thresholds) were calculated for these indices. These cerebral physiology indices were studied for their relationship with age via linear regression, age trichotomization (< 40, 40 - 60, > 60) and decades of age (< 30, 30 - 39, 40 - 49, 50 - 59, 60 - 69, > 69) schemes. Similarly, differences based on biological sex were assessed. A statistically significant positive linear correlation was found between PAx, RAC and age. In corollary, a statistically significant relationship was found between increasing age on trichotomized and decades of age analysis with PAx and RAC measures. PRx failed to demonstrate such relationships to advancing age. There was no clear difference in cerebrovascular reactivity profiles between biological sex categories. These findings suggest that AMP-based cerebrovascular reactivity indices may be better positioned to detect impairment in TBI patients with advancing age. Further investigation into the utility of PAx and RAC is required, as they may prove useful for certain subgroups of patients.
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Affiliation(s)
| | - Logan Froese
- University of Manitoba Faculty of Engineering, Biomedical Engineering, SP-422 EITC, 75 Chancellor`s Circle, Winnipeg, Manitoba, Canada, R3T 5V6;
| | - Mypinder Singh Sekhon
- University of British Columbia, Critical Care Medicine, 899 West 12th Avenue, Vancouver, British Columbia, Canada, V5Z 1M9;
| | - Donald E Griesdale
- University of British Columbia, Anesthesiology, Pharmacology and Therapeutics, Vancouver, British Columbia, Canada;
| | - Alwyn Gomez
- University of Manitoba Faculty of Health Sciences, Surgery, GF231, Health Sciences Centre, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Eric Peter Thelin
- Karolinska Institutet, Department of Clinical Neuroscience, Neurosurgical Research Laboratory, Building R2:02, Karolinska University Hospital, Stockholm, Sweden, 171 76;
| | - Rahul Raj
- HUS, Topeliuksenkatu 5, Helsinki, Finland, 00029 HUS;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Clare N Gallagher
- University of Calgary, Department of Clinical Neurosciences, Calgary, Alberta, Canada;
| | - Francis Bernard
- Hôpital du Sacré-Coeur de Montreal, Intensive Care Unit, 5400 Boul Gouin O, Montreal, Quebec, Canada, H4J1C5;
| | - Andreas H Kramer
- University of Calgary, Departments of Critical Care Medicine and Clinical Neurosciences, 3132 Hospital Drive NW, Calgary, Calgary, Alberta, Canada, T2N 2T9;
| | - Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
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21
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Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
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Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
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22
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Mainali S, Cardim D, Sarwal A, Merck LH, Yeatts SD, Czosnyka M, Shutter L. Prolonged Automated Robotic TCD Monitoring in Acute Severe TBI: Study Design and Rationale. Neurocrit Care 2022; 37:267-275. [PMID: 35381966 DOI: 10.1007/s12028-022-01483-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasonography (TCD) is a portable, bedside, noninvasive diagnostic tool used for the real-time assessment of cerebral hemodynamics. Despite the evident utility of TCD and the ability of this technique to function as a stethoscope to the brain, its use has been limited to specialized centers because of the dearth of technical and clinical expertise required to acquire and interpret the cerebrovascular parameters. Additionally, the conventional pragmatic episodic TCD monitoring protocols lack dynamic real-time feedback to guide time-critical clinical interventions. Fortunately, with the recent advent of automated robotic TCD technology in conjunction with the automated software for TCD data processing, we now have the technology to automatically acquire TCD data and obtain clinically relevant information in real-time. By obviating the need for highly trained clinical personnel, this technology shows great promise toward a future of widespread noninvasive monitoring to guide clinical care in patients with acute brain injury. METHODS Here, we describe a proposal for a prospective observational multicenter clinical trial to evaluate the safety and feasibility of prolonged automated robotic TCD monitoring in patients with severe acute traumatic brain injury (TBI). We will enroll patients with severe non-penetrating TBI with concomitant invasive multimodal monitoring including, intracranial pressure, brain tissue oxygenation, and brain temperature monitoring as part of standard of care in centers with varying degrees of TCD availability and experience. Additionally, we propose to evaluate the correlation of pertinent TCD-based cerebral autoregulation indices such as the critical closing pressure, and the pressure reactivity index with the brain tissue oxygenation values obtained invasively. CONCLUSIONS The overarching goal of this study is to establish safety and feasibility of prolonged automated TCD monitoring for patients with TBI in the intensive care unit and identify clinically meaningful and pragmatic noninvasive targets for future interventions.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginial Commonwealth University, Richmond, VA, USA.
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Lisa H Merck
- Departments of Emergency Medicine and Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Marek Czosnyka
- Brain Physics Laboratory, Neurosurgical Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
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Continuous Determination of the Optimal Bispectral Index Value Based on Cerebrovascular Reactivity in Moderate/Severe Traumatic Brain Injury: A Retrospective Observational Cohort Study of a Novel Individualized Sedation Target. Crit Care Explor 2022; 4:e0656. [PMID: 35265854 PMCID: PMC8901214 DOI: 10.1097/cce.0000000000000656] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Batson C, Stein KY, Gomez A, Sainbhi AS, Froese L, Alizadeh A, Mathieu F, Zeiler FA. Intracranial Pressure-Derived Cerebrovascular Reactivity Indices, Chronological Age, and Biological Sex in Traumatic Brain Injury: A Scoping Review. Neurotrauma Rep 2022; 3:44-56. [PMID: 35112107 PMCID: PMC8804238 DOI: 10.1089/neur.2021.0054] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
To date, there has been limited literature exploring the association between age and sex with cerebrovascular reactivity (CVR) in moderate/severe traumatic brain injury (TBI). Given the known link between age, sex, and cerebrovascular function, knowledge of the impacts on continuously assessed CVR is critical for the development of future therapeutics. We conducted a scoping review of the literature for studies that had a direct statistical interrogation of the relationship between age, sex, and continuous intracranial pressure (ICP)-based indices of CVR in moderate/severe TBI. The ICP-based indices researched included: pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC. MEDLINE, BIOSIS, EMBASE, SCOPUS, Global Health, and the Cochrane library were searched from inception to June 2021 for relevant articles. A total of 10 original studies fulfilled our inclusion criteria. Nine of the articles documented a correlation between advanced age and worse CVR, with eight using PRx (2192 total patients), three using PAx (978 total patients), and one using RAC (358 total patients), p < 0.05; R ranging from 0.17 to 0.495 for all indices across all studies. Three articles (1256 total patients) displayed a correlation between biological sex and PRx, with females trending towards higher PRx values (p < 0.05) in the limited available literature. However, no literature exists comparing PAx or RAC with biological sex. Findings showed that aging was associated with impaired CVR. We observed a trend between female sex and worse PRx values, but the literature was limited and statistical significance was borderline. The identified studies were few in number, carried significant population heterogeneity, and utilized grand averaging of large epochs of physiology during statistical comparisons with age and biological sex. Because of the heterogeneous nature of TBI populations and limited focus on the effects of age and sex on outcomes in TBI, it is challenging to highlight the differences between the indices and patient age groups and sex. The largest study showing an association between PRx and age was done by Zeiler and colleagues, where 165 patients were studied noting that patients with a mean PRx value above zero had a mean age above 51.4 years versus a mean age of 41.4 years for those with a mean PRx value below zero (p = 0.0007). The largest study showing an association between PRx and sex was done by Czosnyka and colleagues, where 469 patients were studied noting that for patients <50 years of age, PRx was worse in females (0.11 ± 0.047) compared to males (0.044 ± 0.031), p < 0.05. The findings from these 10 studies provide preliminary data, but are insufficient to definitively characterize the impact of age and sex on CVR in moderate/severe TBI. Future work in the field should focus on the impact of age and sex on multi-modal cerebral physiological monitoring.
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Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Batson C, Gomez A, Sainbhi AS, Froese L, Zeiler FA. Association of Age and Sex With Multi-Modal Cerebral Physiology in Adult Moderate/Severe Traumatic Brain Injury: A Narrative Overview and Future Avenues for Personalized Approaches. Front Pharmacol 2021; 12:676154. [PMID: 34899283 PMCID: PMC8652202 DOI: 10.3389/fphar.2021.676154] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/04/2021] [Accepted: 10/22/2021] [Indexed: 12/30/2022] Open
Abstract
The impact of age and biological sex on outcome in moderate/severe traumatic brain injury (TBI) has been documented in large cohort studies, with advanced age and male sex linked to worse long-term outcomes. However, the association between age/biological sex and high-frequency continuous multi-modal monitoring (MMM) cerebral physiology is unclear, with only sparing reference made in guidelines and major literature in moderate/severe TBI. In this narrative review, we summarize some of the largest studies associating various high-frequency MMM parameters with age and biological sex in moderate/severe TBI. To start, we present this by highlighting the representative available literature on high-frequency data from Intracranial Pressure (ICP), Cerebral Perfusion Pressure (CPP), Extracellular Brain Tissue Oxygenation (PbtO2), Regional Cerebral Oxygen Saturations (rSO2), Cerebral Blood Flow (CBF), Cerebral Blood Flow Velocity (CBFV), Cerebrovascular Reactivity (CVR), Cerebral Compensatory Reserve, common Cerebral Microdialysis (CMD) Analytes and their correlation to age and sex in moderate/severe TBI cohorts. Then we present current knowledge gaps in the literature, discuss biological implications of age and sex on cerebrovascular monitoring in TBI and some future avenues for bedside research into the cerebrovascular physiome after TBI.
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Affiliation(s)
- C Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - A Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - A S Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - L Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - F A Zeiler
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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26
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Gomez A, Sainbhi AS, Froese L, Batson C, Alizadeh A, Mendelson AA, Zeiler FA. Near Infrared Spectroscopy for High-Temporal Resolution Cerebral Physiome Characterization in TBI: A Narrative Review of Techniques, Applications, and Future Directions. Front Pharmacol 2021; 12:719501. [PMID: 34803673 PMCID: PMC8602694 DOI: 10.3389/fphar.2021.719501] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 10/22/2021] [Indexed: 12/31/2022] Open
Abstract
Multimodal monitoring has been gaining traction in the critical care of patients following traumatic brain injury (TBI). Through providing a deeper understanding of the individual patient's comprehensive physiologic state, or "physiome," following injury, these methods hold the promise of improving personalized care and advancing precision medicine. One of the modalities being explored in TBI care is near-infrared spectroscopy (NIRS), given it's non-invasive nature and ability to interrogate microvascular and tissue oxygen metabolism. In this narrative review, we begin by discussing the principles of NIRS technology, including spatially, frequency, and time-resolved variants. Subsequently, the applications of NIRS in various phases of clinical care following TBI are explored. These applications include the pre-hospital, intraoperative, neurocritical care, and outpatient/rehabilitation setting. The utility of NIRS to predict functional outcomes and evaluate dysfunctional cerebrovascular reactivity is also discussed. Finally, future applications and potential advancements in NIRS-based physiologic monitoring of TBI patients are presented, with a description of the potential integration with other omics biomarkers.
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Affiliation(s)
- Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Asher A Mendelson
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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27
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Batson C, Froese L, Gomez A, Sainbhi AS, Stein KY, Alizadeh A, Zeiler FA. Impact of Age and Biological Sex on Cerebrovascular Reactivity in Adult Moderate/Severe Traumatic Brain Injury: An Exploratory Analysis. Neurotrauma Rep 2021; 2:488-501. [PMID: 34901944 PMCID: PMC8655816 DOI: 10.1089/neur.2021.0039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Age and biological sex are two potential important modifiers of cerebrovascular reactivity post-traumatic brain injury (TBI) requiring close evaluation for potential subgroup responses. The goal of this study was to provide a preliminary exploratory analysis of the impact of age and biological sex on measures of cerebrovascular function in moderate/severe TBI. Forty-nine patients from the prospectively maintained TBI database at the University of Manitoba with archived high-frequency digital cerebral physiology were evaluated. Cerebrovascular reactivity indices were derived as follows: PRx (correlation between intracranial pressure [ICP] and mean arterial pressure [MAP]), PAx (correlation between pulse amplitude of ICP [AMP] and MAP), and RAC (correlation between AMP and cerebral perfusion pressure [CPP]). Time above clinically significant thresholds for each index was calculated over different periods of the acute intensive care unit stay. The association between PRx, PAx, and RAC measures with age was assessed using linear regression, and an age trichotomization scheme (<40, 40-60, >60) using Kruskal-Wallis testing. Similarly, association with biological sex was tested using Mann-Whitney U testing. Biological sex did not demonstrate an impact on any measures of cerebrovascular reactivity. Linear regression between age and PAx and RAC demonstrated a statistically significant positive linear relationship. Median PAx and RAC measures between trichotomized age categories demonstrated statistically significant increases with advancing age. The PRx failed to demonstrate any statistically significant relationship with age in this cohort, suggesting that in elderly patients with controlled ICP, PAx and RAC may be better metrics for detecting impaired cerebrovascular reactivity. Biological sex appears to not be associated with differences in cerebrovascular reactivity in this cohort. The PRx performed the worst in detecting impaired cerebrovascular reactivity in those with advanced age, where PAx and RAC appear to have excelled. Future work is required to validate these findings and explore the utility of different cerebrovascular reactivity indices.
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Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Toro C, Temkin N, Barber J, Manley G, Jain S, Ohnuma T, Komisarow J, Foreman B, Korley FK, Vavilala MS, Laskowitz DT, Mathew JP, Hernandez A, Sampson J, James ML, Goldstein BA, Markowitz AJ, Krishnamoorthy V. Association of Vasopressor Choice with Clinical and Functional Outcomes Following Moderate to Severe Traumatic Brain Injury: A TRACK-TBI Study. Neurocrit Care 2021; 36:180-191. [PMID: 34341913 DOI: 10.1007/s12028-021-01280-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2021] [Accepted: 05/17/2021] [Indexed: 11/26/2022]
Abstract
BACKGROUND Early hypotension following moderate to severe traumatic brain injury (TBI) is associated with increased mortality and poor long-term outcomes. Current guidelines suggest the use of intravenous vasopressors to support blood pressure following TBI; however, guidelines do not specify vasopressor type, resulting in variation in clinical practice. Minimal data are available to guide clinicians on optimal early vasopressor choice to support blood pressure following TBI. Therefore, we conducted a multicenter study to examine initial vasopressor choice for the support of blood pressure following TBI and its association with clinical and functional outcomes after injury. METHODS We conducted a retrospective cohort study of patients enrolled in the transforming research and clinical knowledge in traumatic brain injury (TRACK-TBI) study, an 18-center prospective cohort study of patients with TBI evaluated in participating level I trauma centers. We examined adults with moderate to severe TBI (defined as Glasgow Coma Scale score < 13) who were admitted to the intensive care unit and received an intravenous vasopressor within 48 h of admission. The primary exposure was initial vasopressor choice (phenylephrine versus norepinephrine), and the primary outcome was 6-month Glasgow Outcomes Scale Extended (GOSE), with the following secondary outcomes: length of hospital stay, length of intensive care unit stay, in-hospital mortality, new requirement for dialysis, and 6-month Disability Rating Scale. Regression analysis was used to assess differences in outcomes between patients exposed to norepinephrine versus phenylephrine, with propensity weighting to address selection bias due to the nonrandom allocation of the treatment groups and patient dropout. RESULTS The final study sample included 156 patients, of whom 79 (51%) received norepinephrine, 69 (44%) received phenylephrine, and 8 (5%) received an alternate drug as their initial vasopressor. 121 (77%) of patients were men, with a mean age of 43.1 years. Of patients receiving norepinephrine as their initial vasopressor, 32% had a favorable outcome (GOSE 5-8), whereas 40% of patients receiving phenylephrine as their initial vasopressor had a favorable outcome. Compared with phenylephrine, exposure to norepinephrine was not significantly associated with improved 6-month GOSE (weighted odds ratio 1.40, 95% confidence interval 0.66-2.96, p = 0.37) or any secondary outcome. CONCLUSIONS The majority of patients with moderate to severe TBI received either phenylephrine or norepinephrine as first-line agents for blood pressure support following brain injury. Initial choice of norepinephrine, compared with phenylephrine, was not associated with improved clinical or functional outcomes.
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Affiliation(s)
- Camilo Toro
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Duke University School of Medicine, Durham, NC, USA
| | - Nancy Temkin
- Department of Biostatistics, University of Washington, Seattle, WA, USA
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Jason Barber
- Department of Neurosurgery, University of Washington, Seattle, WA, USA
| | - Geoffrey Manley
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, USA
| | - Sonia Jain
- Biostatistics Research Center, Herbert Wertheim School of Public Health and Human Longevity Science, University of California, San Diego, CA, USA
| | - Tetsu Ohnuma
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| | - Frederick K Korley
- Department of Emergency Medicine, University of Michigan, Ann Arbor, MI, USA
| | - Monica S Vavilala
- Department of Anesthesiology and Pain Medicine, University of Washington, Seattle, WA, USA
| | - Daniel T Laskowitz
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurosurgery, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Joseph P Mathew
- Department of Anesthesiology, Duke University, Durham, NC, USA
| | | | - John Sampson
- Department of Neurosurgery, Duke University, Durham, NC, USA
| | - Michael L James
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Anesthesiology, Duke University, Durham, NC, USA
- Department of Neurology, Duke University, Durham, NC, USA
| | - Benjamin A Goldstein
- Department of Biostatistics and Bioinformatics, Duke University, Durham, NC, USA
| | - Amy J Markowitz
- Brain and Spinal Injury Center, University of California, San Francisco, San Francisco, CA, USA
| | - Vijay Krishnamoorthy
- Critical Care and Perioperative Population Health Research Unit, Department of Anesthesiology, Duke University, Durham, NC, USA.
- Department of Anesthesiology, Duke University, Durham, NC, USA.
- Department of Population Health Sciences, Duke University, Durham, NC, USA.
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Brain Temperature Influences Intracranial Pressure and Cerebral Perfusion Pressure After Traumatic Brain Injury: A CENTER-TBI Study. Neurocrit Care 2021; 35:651-661. [PMID: 34331210 PMCID: PMC8692292 DOI: 10.1007/s12028-021-01294-1] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/06/2020] [Accepted: 06/09/2021] [Indexed: 11/05/2022]
Abstract
Background After traumatic brain injury (TBI), fever is frequent. Brain temperature (BT), which is directly linked to body temperature, may influence brain physiology. Increased body and/or BT may cause secondary brain damage, with deleterious effects on intracranial pressure (ICP), cerebral perfusion pressure (CPP), and outcome. Methods Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI), a prospective multicenter longitudinal study on TBI in Europe and Israel, includes a high resolution cohort of patients with data sampled at a high frequency (from 100 to 500 Hz). In this study, simultaneous BT, ICP, and CPP recordings were investigated. A mixed-effects linear model was used to examine the association between different BT levels and ICP. We additionally focused on changes in ICP and CPP during the episodes of BT changes (Δ BT ≥ 0.5 °C lasting from 15 min to 3 h) up or downward. The significance of ICP and CPP variations was estimated with the paired samples Wilcoxon test (also known as Wilcoxon signed-rank test). Results Twenty-one patients with 2,435 h of simultaneous BT and ICP monitoring were studied. All patients reached a BT of 38 °C and experienced at least one episode of ICP above 20 mm Hg. The linear mixed-effects model revealed an association between BT above 37.5 °C and higher ICP levels that was not confirmed for lower BT. We identified 149 episodes of BT changes. During BT elevations (n = 79) ICP increased, whereas CPP was reduced; opposite ICP and CPP variations occurred during episodes of BT reduction (n = 70). All these changes were of moderate clinical relevance (increase of ICP of 4.5 and CPP decrease of 7.5 mm Hg for BT rise, and ICP reduction of 1.7 and CPP elevation of 3.7 mm Hg during BT defervescence), even if statistically significant (p < 0.0001). It has to be noted, however, that a number of therapeutic interventions against intracranial hypertension was documented during those episodes. Conclusions Patients after TBI usually develop BT > 38 °C soon after the injury. BT may influence brain physiology, as reflected by ICP and CPP. An association between BT exceeding 37.5 °C and a higher ICP was identified but not confirmed for lower BT ranges. The relationship between BT, ICP, and CPP become clearer during rapid temperature changes. During episodes of temperature elevation, BT seems to have a significant impact on ICP and CPP.
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Jha RM, Zusman BE, Puccio AM, Okonkwo DO, Pease M, Desai SM, Leach M, Conley YP, Kochanek PM. Genetic Variants Associated With Intraparenchymal Hemorrhage Progression After Traumatic Brain Injury. JAMA Netw Open 2021; 4:e2116839. [PMID: 34309670 PMCID: PMC8314141 DOI: 10.1001/jamanetworkopen.2021.16839] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
IMPORTANCE Intracerebral hemorrhage progression is associated with unfavorable outcome after traumatic brain injury (TBI). No effective treatments are currently available. This secondary injury process reflects an extreme form of vasogenic edema and blood-brain barrier breakdown. The sulfonylurea receptor 1-transient receptor potential melastatin 4 (SUR1-TRPM4) cation channel is a key underlying mechanism. A phase 2 trial of SUR1-TRPM4 inhibition in contusional TBI is ongoing, and a phase 3 trial is being designed. Targeted identification of patients at increased risk for hemorrhage progression may inform prognostication, trial design (including patient selection), and ultimately treatment response. OBJECTIVE To determine whether ABCC8 (SUR1) and TRPM4 genetic variability are associated with intraparenchymal hemorrhage (IPH) progression after severe TBI, based on the putative involvement of the SUR1-TRPM4 channel in this pathophysiology. DESIGN, SETTING, AND PARTICIPANTS In this genetic association study, DNA was extracted from 416 patients with severe TBI prospectively enrolled from a level I trauma academic medical center from May 9, 2002, to August 8, 2014. Forty ABCC8 and TRPM4 single-nucleotide variants (SNVs) were genotyped (multiplex, unbiased). Data were analyzed from January 7, 2020, to May 3, 2021. MAIN OUTCOMES AND MEASURES Primary analyses addressed IPH progression at 6, 24, and 120 hours in patients without acute craniectomy (n = 321). Multivariable regressions and receiver operating characteristic curves assessed SNV and haplotype associations with progression. Spatial modeling and functional predictions were determined using standard software. RESULTS Of the 321 patients included in the analysis (mean [SD] age, 37.0 [16.3] years; 247 [76.9%] male), IPH progression occurred in 102. Four ABCC8 SNVs were associated with markedly increased odds of progression (rs2237982 [odds ratio (OR), 2.60-3.80; 95% CI, 1.14-5.90 to 1.80-8.02; P = .02 to P < .001], rs2283261 [OR, 3.37-4.77; 95% CI, 1.07-10.77 to 1.89-12.07; P = .04 to P = .001], rs3819521 [OR, 2.96-3.92; 95% CI, 1.13-7.75 to 1.42-10.87; P = .03 to P = .009], and rs8192695 [OR, 3.06-4.95; 95% CI, 1.02-9.12 to 1.67-14.68]; P = .03-.004). These are brain-specific expression quantitative trait loci (eQTL) associated with increased ABCC8 messenger RNA levels. Regulatory annotations revealed promoter and enhancer marks and strong and/or active brain-tissue transcription, directionally consistent with increased progression. Three SNVs (rs2283261, rs2237982, and rs3819521) in this cohort have been associated with intracranial hypertension. Four TRPM4 SNVs were associated with decreased IPH progression (rs3760666 [OR, 0.40-0.49; 95% CI, 0.19-0.86 to 0.27-0.89; P = .02 to P = .009], rs1477363 [OR, 0.40-0.43; 95% CI, 0.18-0.88 to 0.23-0.81; P = .02 to P = .006], rs10410857 [OR, 0.36-0.41; 95% CI, 0.20-0.67 to 0.20-0.85; P = .02 to P = .001], and rs909010 [OR, 0.27-0.40; 95% CI, 0.12-0.62 to 0.16-0.58; P = .002 to P < .001]). Significant SNVs in both genes cluster downstream, flanking exons encoding the receptor site and SUR1-TRPM4 binding interface. Adding genetic variation to clinical models improved receiver operating characteristic curve performance from 0.6959 to 0.8030 (P = .003). CONCLUSIONS AND RELEVANCE In this genetic association study, 8 ABCC8 and TRPM4 SNVs were associated with IPH progression. Spatial clustering, brain-specific eQTL, and regulatory annotations suggest biological plausibility. These findings may have important implications for neurocritical care risk stratification, patient selection, and precision medicine, including an upcoming phase 3 trial design for SUR1-TRPM4 inhibition in severe TBI.
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Affiliation(s)
- Ruchira M. Jha
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurological Surgery, Barrow Neurological Institute, Phoenix, Arizona
- Department of Neurobiology, Barrow Neurological Institute, Phoenix, Arizona
| | - Benjamin E. Zusman
- medical student at School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- now affiliated with Department of Medicine, Massachusetts General Hospital, Harvard Medical School, Boston
| | - Ava M. Puccio
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - David O. Okonkwo
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Matthew Pease
- Department of Neurological Surgery, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Shashvat M. Desai
- Department of Neurology, Barrow Neurological Institute, Phoenix, Arizona
| | - Matthew Leach
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Yvette P. Conley
- School of Nursing, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Clinical and Translational Science Institute, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Department of Pediatrics, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
- Safar Center for Resuscitation Research, School of Medicine, University of Pittsburgh, Pittsburgh, Pennsylvania
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Senay B, Chaaban T, Cardim D, Mainali S. Ultrasound-Guided Therapies in the Neuro ICU. Curr Treat Options Neurol 2021. [DOI: 10.1007/s11940-021-00679-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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How do we identify the crashing traumatic brain injury patient - the neurosurgeon's view. Curr Opin Crit Care 2021; 27:87-94. [PMID: 33395087 DOI: 10.1097/mcc.0000000000000799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view. RECENT FINDINGS In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected. SUMMARY Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.
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Appavu B, Foldes S, Burrows BT, Jacobson A, Abruzzo T, Boerwinkle V, Willyerd A, Mangum T, Gunnala V, Marku I, Adelson PD. Multimodal Assessment of Cerebral Autoregulation and Autonomic Function After Pediatric Cerebral Arteriovenous Malformation Rupture. Neurocrit Care 2021; 34:537-546. [PMID: 32748209 DOI: 10.1007/s12028-020-01058-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/30/2020] [Accepted: 07/21/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Management after cerebral arteriovenous malformation (AVM) rupture aims toward preventing hemorrhagic expansion while maintaining cerebral perfusion to avoid secondary injury. We investigated associations of model-based indices of cerebral autoregulation (CA) and autonomic function (AF) with outcomes after pediatric cerebral AVM rupture. METHODS Multimodal neurologic monitoring data from the initial 3 days after cerebral AVM rupture were retrospectively analyzed in children (< 18 years). AF indices included standard deviation of heart rate (HRsd), root-mean-square of successive differences in heart rate (HRrmssd), low-high frequency ratio (LHF), and baroreflex sensitivity (BRS). CA indices include pressure reactivity index (PRx), wavelet pressure reactivity indices (wPRx and wPRx-thr), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Percent time of cerebral perfusion pressure (CPP) below lower limits of autoregulation (LLA) was also computed for each CA index. Primary outcomes were determined using Pediatric Glasgow Outcome Score Extended-Pediatrics (GOSE-PEDs) at 12 months and acquired epilepsy. Association of biomarkers with outcomes was investigated using linear regression, Wilcoxon signed-rank, or Chi-square. RESULTS Fourteen children were analyzed. Lower AF indices were associated with poor outcomes (BRS [p = 0.04], HRsd [p = 0.04], and HRrmssd [p = 0.00]; and acquired epilepsy (LHF [p = 0.027]). Higher CA indices were associated with poor outcomes (PRx [p = 0.00], wPRx [p = 0.00], and wPRx-thr [p = 0.01]), and acquired epilepsy (PRx [p = 0.02] and wPRx [p = 0.00]). Increased time below LLA was associated with poor outcome (percent time below LLA based on PRx [p = 0.00], PAx [p = 0.04], wPRx-thr [p = 0.03], and RAC [p = 0.01]; and acquired epilepsy (PRx [p = 0.00], PAx [p = 0.00], wPRx-thr [p = 0.03], and RAC [p = 0.01]). CONCLUSIONS After pediatric cerebral AVM rupture, poor outcomes are associated with AF and CA when applying various neurophysiologic model-based indices. Prospective work is needed to assess these indices of CA and AF in clinical decision support.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Vishal Gunnala
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd Floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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Gomez A, Dian J, Zeiler FA. Continuous and entirely non-invasive method for cerebrovascular reactivity assessment: technique and implications. J Clin Monit Comput 2021; 35:307-315. [PMID: 31989415 PMCID: PMC7382981 DOI: 10.1007/s10877-020-00472-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 5.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
Continuous cerebrovascular reactivity assessment in traumatic brain injury (TBI) has been limited by the need for invasive monitoring of either cerebral physiology or arterial blood pressure (ABP). This restricts the application of continuous measures to the acute phase of care, typically in the intensive care unit. It remains unknown if ongoing impairment of cerebrovascular reactivity occurs in the subacute and long-term phase, and if it drives ongoing morbidity in TBI. We describe an entirely non-invasive method for continuous assessment of cerebrovascular reactivity. We describe the technique for entirely non-invasive continuous assessment of cerebrovascular reactivity utilizing near-infrared spectroscopy (NIRS) and robotic transcranial Doppler (rTCD) technology, with details provided for NIRS. Recent advances in continuous high-frequency non-invasive ABP measurement, combined with NIRS or rTCD, can be employed to derive continuous and entirely non-invasive cerebrovascular reactivity metrics. Such non-invasive measures can be obtained during any aspect of patient care post-TBI, and even during outpatient follow-up, avoiding classical intermittent techniques and costly neuroimaging based metrics obtained only at specialized centers. This combination of technology and signal analytic techniques creates avenues for future investigation of the long-term consequences of cerebrovascular reactivity, integrating high-frequency non-invasive cerebral physiology, neuroimaging, proteomics and clinical phenotype at various stages post-injury.
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Affiliation(s)
- A Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - J Dian
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - F A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Appavu B, Burrows BT, Nickoles T, Boerwinkle V, Willyerd A, Gunnala V, Mangum T, Marku I, Adelson PD. Implementation of Multimodality Neurologic Monitoring Reporting in Pediatric Traumatic Brain Injury Management. Neurocrit Care 2021; 35:3-15. [PMID: 33791948 PMCID: PMC8012079 DOI: 10.1007/s12028-021-01190-8] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 01/12/2021] [Indexed: 11/28/2022]
Abstract
Background/Objective Multimodality neurologic monitoring (MMM) is an emerging technique for management of traumatic brain injury (TBI). An increasing array of MMM-derived biomarkers now exist that are associated with injury severity and functional outcomes after TBI. A standardized MMM reporting process has not been well described, and a paucity of evidence exists relating MMM reporting in TBI management with functional outcomes or adverse events. Methods Prospective implementation of standardized MMM reporting at a single pediatric intensive care unit (PICU) is described that included monitoring of intracranial pressure (ICP), cerebral oxygenation and electroencephalography (EEG). The incidence of clinical decisions made using MMM reporting is described, including timing of neuroimaging, ICP monitoring discontinuation, use of paralytic, hyperosmolar and pentobarbital therapies, neurosurgical interventions, ventilator and CPP adjustments and neurologic prognostication discussions. Retrospective analysis was performed on the association of MMM reporting with initial Glasgow Coma Scale (GCS) and Pediatric Risk of Mortality III (PRISM III) scores, duration of total hospitalization and PICU hospitalization, duration of mechanical ventilation and invasive ICP monitoring, inpatient complications, time with ICP > 20 mmHg, time with cerebral perfusion pressure (CPP) < 40 mmHg and 12-month Glasgow Outcome Scale—Extended Pediatrics (GOSE-Peds) scores. Association of outcomes with MMM reporting was investigated using the Wilcoxon rank-sum test or Fisher’s exact test, as appropriate. Results Eighty-five children with TBI underwent MMM over 6 years, among which 18 underwent daily MMM reporting over a 21-month period. Clinical decision-making influenced by MMM reporting included timing of neuroimaging (100.0%), ICP monitoring discontinuation (100.0%), timing of extubation trials of surviving patients (100.0%), body repositioning (11.1%), paralytic therapy (16.7%), hyperosmolar therapy (22.2%), pentobarbital therapy (33.3%), provocative cerebral autoregulation testing (16.7%), adjustments in CPP thresholds (16.7%), adjustments in PaCO2 thresholds (11.1%), neurosurgical interventions (16.7%) and neurologic prognostication discussions (11.1%). The implementation of MMM reporting was associated with a reduction in ICP monitoring duration (p = 0.0017) and mechanical ventilator duration (p = 0.0018). No significant differences were observed in initial GCS or PRISM III scores, total hospitalization length, PICU hospitalization length, total complications, time with ICP > 20 mmHg, time with CPP < 40 mmHg, use of tier 2 therapy, or 12-month GOS-E Peds scores. Conclusion Implementation of MMM reporting in pediatric TBI management is feasible and can be impactful in tailoring clinical decisions. Prospective work is needed to understand the impact of MMM and MMM reporting systems on functional outcomes and clinical care efficacy. Supplementary Information The online version contains supplementary material available at 10.1007/s12028-021-01190-8.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute At Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd floor, Phoenix, AZ, 85016, USA.
- Department of Child Health, University Arizona College of Medicine -Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute At Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd floor, Phoenix, AZ, 85016, USA
| | - Todd Nickoles
- Department of Surgery, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
| | - Varina Boerwinkle
- Department of Neurosciences, Barrow Neurological Institute At Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine -Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Anthony Willyerd
- Department of Critical Care Medicine, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
| | - Vishal Gunnala
- Department of Critical Care Medicine, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
| | - Tara Mangum
- Department of Neurosciences, Barrow Neurological Institute At Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine -Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - Iris Marku
- Department of Neurosciences, Barrow Neurological Institute At Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine -Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
| | - P D Adelson
- Department of Neurosciences, Barrow Neurological Institute At Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 3rd floor, Phoenix, AZ, 85016, USA
- Department of Child Health, University Arizona College of Medicine -Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA
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Kow CY, Harley B, Li C, Romo P, Gkolia P, Lu KY, Bell C, Jithoo R, Tee J, Cooper DJ, Rosenfeld JV, Lewis PM, Udy A, Hunn M. Escalating Mean Arterial Pressure in Severe Traumatic Brain Injury: A Prospective, Observational Study. J Neurotrauma 2021; 38:1995-2002. [PMID: 33280492 DOI: 10.1089/neu.2020.7289] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
To investigate cerebral autoregulatory status in patients with severe traumatic brain injury (TBI), guidelines now suggest active manipulation of mean arterial pressure (MAP). There is a paucity of data, however, describing the effect on intracranial pressure (ICP) when MAP is raised. Consecutive patients with TBI requiring ICP monitoring were enrolled from November 2019 to April 2020. The MAP and ICP were recorded continuously, and clinical annotations were made whenever intravenous vasopressors were commenced or adjusted to defend cerebral perfusion pressure (CPP) targets. A significant change in MAP burden was defined as MAP >100min.mm Hg over 15 min. The primary outcome was the change in ICP burden over the same 15-min period. Bedside and clinical parameters were then compared between these groups. Twenty-eight patients were enrolled, providing 212 clinical events, of which 60 were deemed significant. Over the first 15 min, 65% were associated with a net negative ICP burden. A greater reduction in ICP burden was observed with events occurring in patients without a history of hypotension at scene (p = 0.016), after three days post-injury (p = 0.0018), and where the pressure-reactivity index (PRx) was <0.25 (p = 0.0005) or the ICP amplitude to CPP correlation coefficient (RAC) was <-0.10 (p = 0.0036) at the initiation of vasopressor changes. The ICP burden in the first 15 min was highly correlated with the next 15-min period. In patients with severe TBI requiring ICP monitoring, increasing MAP to pursue a CPP target was followed by a net negative ICP burden in approximately two-thirds of events. These data suggest a MAP challenge may be a useful adjunct in managing intracranial hypertension.
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Affiliation(s)
- Chien Yew Kow
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Benjamin Harley
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Charles Li
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia
| | - Phillip Romo
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Panagiota Gkolia
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Kuan-Ying Lu
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia
| | - Catherine Bell
- Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Rondhir Jithoo
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jin Tee
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,National Trauma Research Institute, Melbourne, Victoria, Australia.,Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia
| | - D James Cooper
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Jeffrey V Rosenfeld
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia.,Department of Surgery, and Monash University, Clayton, Victoria, Australia
| | - Philip M Lewis
- Faculty of Medicine, Nursing and Health Sciences, Monash University, Clayton, Victoria, Australia.,Department of Electrical and Computer Systems Engineering, Monash University, Clayton, Victoria, Australia
| | - Andrew Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, Victoria, Australia.,Department of Intensive Care and Hyperbaric Medicine, Alfred Hospital, Melbourne, Victoria, Australia
| | - Martin Hunn
- Neurosurgery Department, Alfred Hospital, Melbourne, Victoria, Australia
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Zeiler FA. Advanced Bio-signal Analytics for Continuous Bedside Monitoring of Aneurysmal Subarachnoid Hemorrhage: The Future. Neurocrit Care 2021; 34:375-378. [PMID: 33403580 DOI: 10.1007/s12028-020-01170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada. .,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada. .,Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada. .,Centre on Aging, University of Manitoba, Winnipeg, Canada. .,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Zeiler FA, Mathieu F, Monteiro M, Glocker B, Ercole A, Cabeleira M, Stocchetti N, Smielewski P, Czosnyka M, Newcombe V, Menon DK. Systemic Markers of Injury and Injury Response Are Not Associated with Impaired Cerebrovascular Reactivity in Adult Traumatic Brain Injury: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2020; 38:870-878. [PMID: 33096953 DOI: 10.1089/neu.2020.7304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of extra-cranial injury burden and systemic injury response on cerebrovascular response in traumatic brain injury (TBI) is poorly documented. This study preliminarily assesses the association between admission features of extra-cranial injury burden on cerebrovascular reactivity. Using the Collaborative European Neurotrauma Effectiveness Research in TBI High-Resolution ICU (HR ICU) sub-study cohort, we evaluated those patients with both archived high-frequency digital intra-parenchymal intra-cranial pressure monitoring data of a minimum of 6 h in duration, and the presence of a digital copy of their admission computed tomography (CT) scan. Digital physiologic signals were processed for pressure reactivity index (PRx) and both the percent time above defined PRx thresholds and mean hourly dose above threshold. This was conducted for both the first 72 h and entire duration of recording. Admission extra-cranial injury characteristics and CT injury scores were obtained from the database, with quantitative contusion, edema, intraventricular hemorrhage, and extra-axial lesion volumes were obtained via semi-automated segmentation. Comparison between admission extra-cranial markers of injury and PRx metrics was conducted using Mann-Whitney U testing, and logistic regression techniques, adjusting for known CT injury metrics associated with impaired PRx. A total of 165 patients were included. Evaluating the entire ICU recording period, there was limited association between metrics of extra-cranial injury burden and impaired cerebrovascular reactivity. Using the first 72 h of recording, admission temperature (p = 0.042) and white blood cell % (WBC %; p = 0.013) were statistically associated with impaired cerebrovascular reactivity on Mann-Whitney U and univariate logistic regression. After adjustment for admission age, pupillary status, GCS motor score, pre-hospital hypoxia/hypotension, and intra-cranial CT characteristics associated with impaired reactivity, temperature (p = 0.021) and WBC % (p = 0.013) remained significantly associated with mean PRx values above +0.25 and +0.35, respectively. Markers of extra-cranial injury burden and systemic injury response do not appear to be strongly associated with impaired cerebrovascular reactivity in TBI during both the initial and entire ICU stay.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Center on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - François Mathieu
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ari Ercole
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia Newcombe
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Thelin EP, Raj R, Bellander BM, Nelson D, Piippo-Karjalainen A, Siironen J, Tanskanen P, Hawryluk G, Hasen M, Unger B, Zeiler FA. Comparison of high versus low frequency cerebral physiology for cerebrovascular reactivity assessment in traumatic brain injury: a multi-center pilot study. J Clin Monit Comput 2020; 34:971-994. [PMID: 31573056 PMCID: PMC7447671 DOI: 10.1007/s10877-019-00392-y] [Citation(s) in RCA: 22] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2019] [Accepted: 09/22/2019] [Indexed: 01/16/2023]
Abstract
Current accepted cerebrovascular reactivity indices suffer from the need of high frequency data capture and export for post-acquisition processing. The role for minute-by-minute data in cerebrovascular reactivity monitoring remains uncertain. The goal was to explore the statistical time-series relationships between intra-cranial pressure (ICP), mean arterial pressure (MAP) and pressure reactivity index (PRx) using both 10-s and minute data update frequency in TBI. Prospective data from 31 patients from 3 centers with moderate/severe TBI and high-frequency archived physiology were reviewed. Both 10-s by 10-s and minute-by-minute mean values were derived for ICP and MAP for each patient. Similarly, PRx was derived using 30 consecutive 10-s data points, updated every minute. While long-PRx (L-PRx) was derived via similar methodology using minute-by-minute data, with L-PRx derived using various window lengths (5, 10, 20, 30, 40, and 60 min; denoted L-PRx_5, etc.). Time-series autoregressive integrative moving average (ARIMA) and vector autoregressive integrative moving average (VARIMA) models were created to analyze the relationship of these parameters over time. ARIMA modelling, Granger causality testing and VARIMA impulse response function (IRF) plotting demonstrated that similar information is carried in minute mean ICP and MAP data, compared to 10-s mean slow-wave ICP and MAP data. Shorter window L-PRx variants, such as L-PRx_5, appear to have a similar ARIMA structure, have a linear association with PRx and display moderate-to-strong correlations (r ~ 0.700, p < 0.0001 for each patient). Thus, these particular L-PRx variants appear closest in nature to standard PRx. ICP and MAP derived via 10-s or minute based averaging display similar statistical time-series structure and co-variance patterns. PRx and L-PRx based on shorter windows also behave similarly over time. These results imply certain L-PRx variants may carry similar information to PRx in TBI.
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Affiliation(s)
- Eric P. Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Theme Neuro, Karolinska University Hospital, Stockholm, Sweden
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Anna Piippo-Karjalainen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jari Siironen
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Päivi Tanskanen
- Division of Anesthesiology, Department of Anesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Gregory Hawryluk
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Mohammed Hasen
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
- Department of Neurosurgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Bertram Unger
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A. Zeiler
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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40
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Froese L, Dian J, Gomez A, Unger B, Zeiler FA. The cerebrovascular response to norepinephrine: A scoping systematic review of the animal and human literature. Pharmacol Res Perspect 2020; 8:e00655. [PMID: 32965778 PMCID: PMC7510331 DOI: 10.1002/prp2.655] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Intravenous norepinephrine (NE) is utilized commonly in critical care for cardiovascular support. NE's impact on cerebrovasculature is unclear and may carry important implications during states of critical neurological illness. The aim of the study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of NE. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019 was performed. All manuscripts pertaining to the administration of NE, in which the impact on CBF/cerebral vasculature was recorded, were included. We identified 62 animal studies and 26 human studies. Overall, there was a trend to a direct vasoconstriction effect of NE on the cerebral vasculature, with conflicting studies having demonstrated both increases and decreases in regional CBF (rCBF) or global CBF. Healthy animals and those undergoing cardiopulmonary resuscitation demonstrated a dose-dependent increase in CBF with NE administration. However, animal models and human patients with acquired brain injury had varied responses in CBF to NE administration. The animal models indicate an increase in cerebral vasoconstriction with NE administration through the alpha receptors in vessels. Global and rCBF during the injection of NE displays a wide variation depending on treatment and model/patient.
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Affiliation(s)
- Logan Froese
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
| | - Joshua Dian
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Alwyn Gomez
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Bertram Unger
- Section of Critical CareDepartment of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Frederick A. Zeiler
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Centre on AgingUniversity of ManitobaWinnipegCanada
- Division of AnaesthesiaDepartment of MedicineAddenbrooke’s HospitalUniversity of CambridgeCambridgeUK
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41
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Chen JW. Commentary: Predictive and Discriminative Power of Pressure Reactivity Indices in Traumatic Brain Injury. Neurosurgery 2020; 87:E496. [PMID: 32243541 DOI: 10.1093/neuros/nyaa083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2020] [Accepted: 02/02/2020] [Indexed: 11/14/2022] Open
Affiliation(s)
- Jefferson W Chen
- Department of Neurological Surgery, University of California, Irvine, Orange, California
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42
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Zeiler FA, Beqiri E, Cabeleira M, Hutchinson PJ, Stocchetti N, Menon DK, Czosnyka M, Smielewski P, Ercole A. Brain Tissue Oxygen and Cerebrovascular Reactivity in Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Exploratory Analysis of Insult Burden. J Neurotrauma 2020; 37:1854-1863. [PMID: 32253987 PMCID: PMC7484893 DOI: 10.1089/neu.2020.7024] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pressure reactivity index (PRx) and brain tissue oxygen (PbtO2) are associated with outcome in traumatic brain injury (TBI). This study explores the relationship between PRx and PbtO2 in adult moderate/severe TBI. Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high resolution intensive care unit (ICU) sub-study cohort, we evaluated those patients with archived high-frequency digital intraparenchymal intracranial pressure (ICP) and PbtO2 monitoring data of, a minimum of 6 h in duration, and the presence of a 6 month Glasgow Outcome Scale -Extended (GOSE) score. Digital physiological signals were processed for ICP, PbtO2, and PRx, with the % time above/below defined thresholds determined. The duration of ICP, PbtO2, and PRx derangements was characterized. Associations with dichotomized 6-month GOSE (alive/dead, and favorable/unfavorable outcome; ≤ 4 = unfavorable), were assessed. A total of 43 patients were included. Severely impaired cerebrovascular reactivity was seen during elevated ICP and low PbtO2 episodes. However, most of the acute ICU physiological derangements were impaired cerebrovascular reactivity, not ICP elevations or low PbtO2 episodes. Low PbtO2 without PRx impairment was rarely seen. % time spent above PRx threshold was associated with mortality at 6 months for thresholds of 0 (area under the curve [AUC] 0.734, p = 0.003), > +0.25 (AUC 0.747, p = 0.002) and > +0.35 (AUC 0.745, p = 0.002). Similar relationships were not seen for % time with ICP >20 mm Hg, and PbtO2 < 20 mm Hg in this cohort. Extreme impairment in cerebrovascular reactivity is seen during concurrent episodes of elevated ICP and low PbtO2. However, the majority of the deranged cerebral physiology seen during the acute ICU phase is impairment in cerebrovascular reactivity, with most impairment occurring in the presence of normal PbtO2 levels. Measures of cerebrovascular reactivity appear to display the most consistent associations with global outcome in TBI, compared with ICP and PbtO2.
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Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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43
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Jacob L, Cogné M, Tenovuo O, Røe C, Andelic N, Majdan M, Ranta J, Ylen P, Dawes H, Azouvi P. Predictors of Access to Rehabilitation in the Year Following Traumatic Brain Injury: A European Prospective and Multicenter Study. Neurorehabil Neural Repair 2020; 34:814-830. [PMID: 32762407 DOI: 10.1177/1545968320946038] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
BACKGROUND Although rehabilitation is beneficial for individuals with traumatic brain injury (TBI), a significant proportion of them do not receive adequate rehabilitation after acute care. OBJECTIVE Therefore, the goal of this prospective and multicenter study was to investigate predictors of access to rehabilitation in the year following injury in patients with TBI. METHODS Data from a large European study (CENTER-TBI), including TBIs of all severities between December 2014 and December 2017 were used (N = 4498 patients). Participants were dichotomized into those who had and those who did not have access to rehabilitation in the year following TBI. Potential predictors included sociodemographic factors, psychoactive substance use, preinjury medical history, injury-related factors, and factors related to medical care, complications, and discharge. RESULTS In the year following traumatic injury, 31.4% of patients received rehabilitation services. Access to rehabilitation was positively and significantly predicted by female sex (odds ratio [OR] = 1.50), increased number of years of education completed (OR = 1.05), living in Northern (OR = 1.62; reference: Western Europe) or Southern Europe (OR = 1.74), lower prehospital Glasgow Coma Scale score (OR = 1.03), higher Injury Severity Score (OR = 1.01), intracranial (OR = 1.33) and extracranial (OR = 1.99) surgery, and extracranial complication (OR = 1.75). On contrast, significant negative predictors were lack of preinjury employment (OR = 0.80), living in Central and Eastern Europe (OR = 0.42), and admission to hospital ward (OR = 0.47; reference: admission to intensive care unit) or direct discharge from emergency room (OR = 0.24). CONCLUSIONS Based on these findings, there is an urgent need to implement national and international guidelines and strategies for access to rehabilitation after TBI.
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Affiliation(s)
- Louis Jacob
- University of Versailles Saint-Quentin-en-Yvelines, Montigny-le-Bretonneux France.,Parc Sanitari Sant Joan de Déu, CIBERSAM, Dr. Antoni Pujadas, Barcelona, Spain
| | - Mélanie Cogné
- University Hospital of Rennes, Rennes, Bretagne, France
| | - Olli Tenovuo
- , Turku University Hospital, Turku, Finland.,University of Turku, Turku, Finland
| | - Cecilie Røe
- Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Nada Andelic
- Oslo University Hospital, Oslo, Norway.,University of Oslo, Oslo, Norway
| | - Marek Majdan
- Institute for Global Health and Epidemiology, Department of Public Health, Trnava University, Trnava, Slovakia
| | - Jukka Ranta
- VTT Technical Research Centre of Finland Ltd, Espoo, Uusimaa, Finland
| | - Peter Ylen
- VTT Technical Research Centre of Finland Ltd, Espoo, Uusimaa, Finland
| | | | - Philippe Azouvi
- Raymond Poincaré Hospital, AP-HP, Garches, France.,Université Paris-Saclay, UVSQ, Versailles, France
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44
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Zeiler FA, Mathieu F, Monteiro M, Glocker B, Ercole A, Beqiri E, Cabeleira M, Stocchetti N, Smielewski P, Czosnyka M, Newcombe V, Menon DK. Diffuse Intracranial Injury Patterns Are Associated with Impaired Cerebrovascular Reactivity in Adult Traumatic Brain Injury: A CENTER-TBI Validation Study. J Neurotrauma 2020; 37:1597-1608. [PMID: 32164482 PMCID: PMC7336886 DOI: 10.1089/neu.2019.6959] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Recent single-center retrospective analysis displayed the association between admission computed tomography (CT) markers of diffuse intracranial injury and worse cerebrovascular reactivity. The goal of this study was to further explore these associations using the prospective multi-center Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high-resolution intensive care unit (HR ICU) data set. Using the CENTER-TBI HR ICU sub-study cohort, we evaluated those patients with both archived high-frequency digital physiology (100 Hz or higher) and the presence of a digital admission CT scan. Physiological signals were processed for pressure reactivity index (PRx) and both the percent (%) time above defined PRx thresholds and mean hourly dose above threshold. Admission CT injury scores were obtained from the database. Quantitative contusion, edema, intraventricular hemorrhage (IVH), and extra-axial lesion volumes were obtained via semi-automated segmentation. Comparison between admission CT characteristics and PRx metrics was conducted using Mann-U, Jonckheere-Terpstra testing, with a combination of univariate linear and logistic regression techniques. A total of 165 patients were included. Cisternal compression and high admission Rotterdam and Helsinki CT scores, and Marshall CT diffuse injury sub-scores were associated with increased percent (%) time and hourly dose above PRx threshold of 0, +0.25, and +0.35 (p < 0.02 for all). Logistic regression analysis displayed an association between deep peri-contusional edema and mean PRx above a threshold of +0.25. These results suggest that diffuse injury patterns, consistent with acceleration/deceleration forces, are associated with impaired cerebrovascular reactivity. Diffuse admission intracranial injury patterns appear to be consistently associated with impaired cerebrovascular reactivity, as measured through PRx. This is in keeping with the previous single-center retrospective literature on the topic. This study provides multi-center validation for those results, and provides preliminary data to support potential risk stratification for impaired cerebrovascular reactivity based on injury pattern.
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Affiliation(s)
- Frederick A. Zeiler
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, and University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - François Mathieu
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ari Ercole
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia Newcombe
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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45
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Mathieu F, Zeiler FA, Ercole A, Monteiro M, Kamnitsas K, Glocker B, Whitehouse DP, Das T, Smielewski P, Czosnyka M, Hutchinson PJ, Newcombe VF, Menon DK. Relationship between Measures of Cerebrovascular Reactivity and Intracranial Lesion Progression in Acute Traumatic Brain Injury Patients: A CENTER-TBI Study. J Neurotrauma 2020; 37:1556-1565. [PMID: 31928143 PMCID: PMC7307675 DOI: 10.1089/neu.2019.6814] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Failure of cerebral autoregulation has been linked to unfavorable outcome after traumatic brain injury (TBI). Preliminary evidence from a small, retrospective, single-center analysis suggests that autoregulatory dysfunction may be associated with traumatic lesion expansion, particularly for pericontusional edema. The goal of this study was to further explore these associations using prospective, multi-center data from the Collaborative European Neurotrauma Effectiveness Research in TBI (CENTER-TBI) and to further explore the relationship between autoregulatory failure, lesion progression, and patient outcome. A total of 88 subjects from the CENTER-TBI High Resolution ICU Sub-Study cohort were included. All patients had an admission computed tomography (CT) scan and early repeat scan available, as well as high-frequency neurophysiological recordings covering the between-scan interval. Using a novel, semiautomated approach at lesion segmentation, we calculated absolute changes in volume of contusion core, pericontusional edema, and extra-axial hemorrhage between the imaging studies. We then evaluated associations between cerebrovascular reactivity metrics and radiological lesion progression using mixed-model regression. Analyses were adjusted for baseline covariates and non-neurophysiological factors associated with lesion growth using multi-variate methods. Impairment in cerebrovascular reactivity was significantly associated with progression of pericontusional edema and, to a lesser degree, intraparenchymal hemorrhage. In contrast, there were no significant associations with extra-axial hemorrhage. The strongest relationships were observed between RAC-based metrics and edema formation. Pulse amplitude index showed weaker, but consistent, associations with contusion growth. Cerebrovascular reactivity metrics remained strongly associated with lesion progression after taking into account contributions from non-neurophysiological factors and mean cerebral perfusion pressure. Total hemorrhagic core and edema volumes on repeat CT were significantly larger in patients who were deceased at 6 months, and the amount of edema was greater in patients with an unfavourable outcome (Glasgow Outcome Scale-Extended 1-4). Our study suggests associations between autoregulatory failure, traumatic edema progression, and poor outcome. This is in keeping with findings from a single-center retrospective analysis, providing multi-center prospective data to support those results.
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Affiliation(s)
- François Mathieu
- Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnibeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnibeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnibeg, Manitoba, Canada
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | | | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | | | - Tilak Das
- Department of Radiology, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter J. Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, Cambridge, United Kingdom
| | | | - David K. Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
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46
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Hasen M, Gomez A, Froese L, Dian J, Raj R, Thelin EP, Zeiler FA. Alternative continuous intracranial pressure-derived cerebrovascular reactivity metrics in traumatic brain injury: a scoping overview. Acta Neurochir (Wien) 2020; 162:1647-1662. [PMID: 32385635 DOI: 10.1007/s00701-020-04378-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pressure reactivity index (PRx) has emerged as a means to continuously monitor cerebrovascular reactivity in traumatic brain injury (TBI). However, other intracranial pressure (ICP)-based continuous metrics exist, and may have advantages over PRx. The goal of this study was to perform a scoping overview of the literature on non-PRx ICP-based continuous cerebrovascular reactivity metrics in adult TBI. METHODS We searched MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019. Using a two-stage filtering of title/abstract, and then full manuscript, we identified pertinent articles. Data was abstracted to tables and each technique summarized, including pulse amplitude index (PAx), correlation between pulse amplitude of ICP and cerebral perfusion pressure (RAC), PRx55-15, and low-resolution metrics LAx and L-PRx. RESULTS A total of 23 articles met the inclusion criteria, with the vast majority being retrospective in nature and based out of European centers. Sixteen articles focused on high-resolution metrics PAx, RAC, and PRx55-15, with 6 articles focusing on LAx and L-PRx. PAx may have a role in low ICP situations, where it appears to perform superior to PRx. RAC displays similar behavior to PRx, with a trend to stronger associations with favorable/unfavorable outcome at 6 months, and stronger parabolic relationship with CPP. PRx55-15 provides a focused assessment on the vasogenic frequency range associated with cerebral autoregulation, with preliminary data supporting a strong association with outcome in TBI. LAx and L-PRx display varying associations with 6-month outcome in TBI, depending on the window length of calculation, with shorter windows demonstrating stronger correlations with classical PRx. CONCLUSIONS Non-PRx continuous ICP-based cerebrovascular reactivity metrics can be split into high-resolution and low-resolution measures. High-resolution indices include PAx, RAC, and PRx55-15, while low-resolution indices include L-PRx and LAx. The true role for these metrics beyond classic PRx remains unclear. Each displays situations where it may prove superior over PRx, given limitations with this currently widely accepted measure. Much future investigation into each of these alternative metrics is required prior to adoption into the clinical monitoring armamentarium in adult TBI.
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Affiliation(s)
- Mohammed Hasen
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
- Department of Neurosurgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alwyn Gomez
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Joshua Dian
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Frederick A Zeiler
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada.
- Centre on Aging, University of Manitoba, Winnipeg, Canada.
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
- Department of Medicine, Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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47
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Zeiler FA, Aries M, Cabeleira M, van Essen TA, Stocchetti N, Menon DK, Timofeev I, Czosnyka M, Smielewski P, Hutchinson P, Ercole A. Statistical Cerebrovascular Reactivity Signal Properties after Secondary Decompressive Craniectomy in Traumatic Brain Injury: A CENTER-TBI Pilot Analysis. J Neurotrauma 2020; 37:1306-1314. [PMID: 31950876 PMCID: PMC7249464 DOI: 10.1089/neu.2019.6726] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022] Open
Abstract
Decompressive craniectomy (DC) in traumatic brain injury (TBI) has been suggested to influence cerebrovascular reactivity. We aimed to determine if the statistical properties of vascular reactivity metrics and slow-wave relationships were impacted after DC, as such information would allow us to comment on whether vascular reactivity monitoring remains reliable after craniectomy. Using the CENTER-TBI High Resolution Intensive Care Unit (ICU) Sub-Study cohort, we selected those secondary DC patients with high-frequency physiological data for both at least 24 h pre-DC, and more than 48 h post-DC. Data for all physiology measures were separated into the 24 h pre-DC, the first 48 h post-DC, and beyond 48 h post-DC. We produced slow-wave data sheets for intracranial pressure (ICP) and mean arterial pressure (MAP) per patient. We also derived a Pressure Reactivity Index (PRx) as a continuous cerebrovascular reactivity metric updated every minute. The time-series behavior of the PRx was modeled for each time period per patient. Finally, the relationship between ICP and MAP during these three time periods was assessed using time-series vector autoregressive integrative moving average (VARIMA) models, impulse response function (IRF) plots, and Granger causality testing. Ten patients were included in this study. Mean PRx and proportion of time above PRx thresholds were not affected by craniectomy. Similarly, PRx time-series structure was not affected by DC, when assessed in each individual patient. This was confirmed with Granger causality testing, and VARIMA IRF plotting for the MAP/ICP slow-wave relationship. PRx metrics and statistical time-series behavior appear not to be substantially influenced by DC. Similarly, there is little change in the relationship between slow waves of ICP and MAP before and after DC. This may suggest that cerebrovascular reactivity monitoring in the setting of DC may still provide valuable information regarding autoregulation.
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Affiliation(s)
- Frederick A. Zeiler
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Thomas A. van Essen
- University Neurosurgical Center Holland, Department of Neurosurgery, Leiden University Medical Center and Haaglanden Medical Center, Leiden and The Hague, The Netherlands
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - David K. Menon
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ivan Timofeev
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Froese L, Batson C, Gomez A, Dian J, Zeiler FA. The Limited Impact of Current Therapeutic Interventions on Cerebrovascular Reactivity in Traumatic Brain Injury: A Narrative Overview. Neurocrit Care 2020; 34:325-335. [PMID: 32468328 DOI: 10.1007/s12028-020-01003-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Current intensive care unit (ICU) treatment strategies for traumatic brain injury (TBI) care focus on intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-directed therapeutics, dictated by guidelines. Impaired cerebrovascular reactivity in moderate/severe TBI is emerging as a major associate with poor outcome and appears to dominate the landscape of physiologic derangement over the course of a patient's ICU stay. Within this article, we review the literature on the known drivers of impaired cerebrovascular reactivity in adult TBI, highlight the current knowledge surrounding the impact of guideline treatment strategies on continuously monitored cerebrovascular reactivity, and discuss current treatment paradigms for impaired reactivity. Finally, we touch on the areas of future research, as we strive to develop specific therapeutics for impaired cerebrovascular reactivity in TBI. There exists limited literature to suggest advanced age, intracranial injury patterns of diffuse injury, and sustained ICP elevations may drive impaired cerebrovascular reactivity. To date, the literature suggests there is a limited impact of such ICP/CPP guideline-based therapies on cerebrovascular reactivity, with large portions of a given patients ICU period spent with impaired cerebrovascular reactivity. Emerging treatment paradigms focus on the targeting individualized CPP and ICP thresholds based on cerebrovascular reactivity, without directly targeting the pathways involved in its dysfunction. Further work involved in uncovering the molecular pathways involved in impaired cerebrovascular reactivity is required, so that we can develop therapeutics directed at its prevention and treatment.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Josh Dian
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Centre on Aging, University of Manitoba, Winnipeg, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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49
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Riemann L, Beqiri E, Smielewski P, Czosnyka M, Stocchetti N, Sakowitz O, Zweckberger K, Unterberg A, Younsi A. Low-resolution pressure reactivity index and its derived optimal cerebral perfusion pressure in adult traumatic brain injury: a CENTER-TBI study. Crit Care 2020; 24:266. [PMID: 32456684 PMCID: PMC7251676 DOI: 10.1186/s13054-020-02974-8] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 05/12/2020] [Indexed: 12/16/2022] Open
Abstract
BACKGROUND After traumatic brain injury (TBI), brain tissue can be further damaged when cerebral autoregulation is impaired. Managing cerebral perfusion pressure (CPP) according to computed "optimal CPP" values based on cerebrovascular reactivity indices might contribute to preventing such secondary injuries. In this study, we examined the discriminative value of a low-resolution long pressure reactivity index (LPRx) and its derived "optimal CPP" in comparison to the well-established high-resolution pressure reactivity index (PRx). METHODS Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study dataset, the association of LPRx (correlation between 1-min averages of intracranial pressure and arterial blood pressure over a moving time frame of 20 min) and PRx (correlation between 10-s averages of intracranial pressure and arterial blood pressure over a moving time frame of 5 min) to outcome was assessed and compared using univariate and multivariate regression analysis. "Optimal CPP" values were calculated using a multi-window algorithm that was based on either LPRx or PRx, and their discriminative ability was compared. RESULTS LPRx and PRx were both significant predictors of mortality in univariate and multivariate regression analysis, but PRx displayed a higher discriminative ability. Similarly, deviations of actual CPP from "optimal CPP" values calculated from each index were significantly associated with outcome in univariate and multivariate analysis. "Optimal CPP" based on PRx, however, trended towards more precise predictions. CONCLUSIONS LPRx and its derived "optimal CPP" which are based on low-resolution data were significantly associated with outcome after TBI. However, they did not reach the discriminative ability of the high-resolution PRx and its derived "optimal CPP." Nevertheless, LPRx might still be an interesting tool to assess cerebrovascular reactivity in centers without high-resolution signal monitoring. TRIAL REGISTRATION ClinicalTrials.gov Identifier: NCT02210221. First submitted July 29, 2014. First posted August 6, 2014.
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Affiliation(s)
- Lennart Riemann
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nino Stocchetti
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Oliver Sakowitz
- Department of Neurosurgery, Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Klaus Zweckberger
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany
| | - Alexander Younsi
- Department of Neurosurgery, Heidelberg University Hospital, INF 400, 69120, Heidelberg, Germany.
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50
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Koskinen LOD, Sundström N, Hägglund L, Eklund A, Olivecrona M. Prostacyclin Affects the Relation Between Brain Interstitial Glycerol and Cerebrovascular Pressure Reactivity in Severe Traumatic Brain Injury. Neurocrit Care 2020; 31:494-500. [PMID: 31123992 PMCID: PMC6872514 DOI: 10.1007/s12028-019-00741-4] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background Cerebral injury may alter the autoregulation of cerebral blood flow. One index for describing cerebrovascular state is the pressure reactivity (PR). Little is known of whether PR is associated with measures of brain metabolism and indicators of ischemia and cell damage. The aim of this investigation was to explore whether increased interstitial levels of glycerol, a marker of cell membrane damage, are associated with PR, and if prostacyclin, a membrane stabilizer and regulator of the microcirculation, may affect this association in a beneficial way. Materials and Methods Patients suffering severe traumatic brain injury (sTBI) were treated according to an intracranial pressure (ICP)-targeted therapy based on the Lund concept and randomized to an add-on treatment with prostacyclin or placebo. Inclusion criteria were verified blunt head trauma, Glasgow Coma Score ≤ 8, age 15–70 years, and a first measured cerebral perfusion pressure of ≥ 10 mmHg. Multimodal monitoring was applied. A brain microdialysis catheter was placed on the worst affected side, close to the penumbra zone. Mean (glycerolmean) and maximal glycerol (glycerolmax) during the 96-h sampling period were calculated. The mean PR was calculated as the ICP/mean arterial pressure (MAP) regression coefficient based on hourly mean ICP and MAP during the first 96 h. Results Of the 48 included patients, 45 had valid glycerol and PR measurements available. PR was higher in the placebo group as compared to the prostacyclin group (p = 0.0164). There was a positive correlation between PR and the glycerolmean (ρ = 0.503, p = 0.01) and glycerolmax (ρ = 0.490, p = 0.015) levels in the placebo group only. Conclusions PR is correlated to the glycerol level in patients suffering from sTBI, a relationship that is not seen in the group treated with prostacyclin. Glycerol has been associated with membrane degradation and may support glycerol as a biomarker for vascular endothelial breakdown. Such a breakdown may impair the regulation of cerebrovascular PR.
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Affiliation(s)
- Lars-Owe D Koskinen
- Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, 901 85, Umeå, Sweden.
| | - Nina Sundström
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Linda Hägglund
- Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, 901 85, Umeå, Sweden
| | - Anders Eklund
- Department of Radiation Sciences, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Department of Pharmacology and Clinical Neuroscience, Neurosurgery, Umeå University, 901 85, Umeå, Sweden
- Department of Anaesthesia and Intensive Care, Section for Neurosurgery, Faculty of Health and Medicine, Department for Medical Sciences, Örebro University, Örebro, Sweden
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