101
|
Detection of Impaired Cerebral Autoregulation Using Selected Correlation Analysis: A Validation Study. COMPUTATIONAL AND MATHEMATICAL METHODS IN MEDICINE 2017; 2017:8454527. [PMID: 28255331 PMCID: PMC5307252 DOI: 10.1155/2017/8454527] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 10/26/2016] [Revised: 01/02/2017] [Accepted: 01/09/2017] [Indexed: 01/08/2023]
Abstract
Multimodal brain monitoring has been utilized to optimize treatment of patients with critical neurological diseases. However, the amount of data requires an integrative tool set to unmask pathological events in a timely fashion. Recently we have introduced a mathematical model allowing the simulation of pathophysiological conditions such as reduced intracranial compliance and impaired autoregulation. Utilizing a mathematical tool set called selected correlation analysis (sca), correlation patterns, which indicate impaired autoregulation, can be detected in patient data sets (scp). In this study we compared the results of the sca with the pressure reactivity index (PRx), an established marker for impaired autoregulation. Mean PRx values were significantly higher in time segments identified as scp compared to segments showing no selected correlations (nsc). The sca based approach predicted cerebral autoregulation failure with a sensitivity of 78.8% and a specificity of 62.6%. Autoregulation failure, as detected by the results of both analysis methods, was significantly correlated with poor outcome. Sca of brain monitoring data detects impaired autoregulation with high sensitivity and sufficient specificity. Since the sca approach allows the simultaneous detection of both major pathological conditions, disturbed autoregulation and reduced compliance, it may become a useful analysis tool for brain multimodal monitoring data.
Collapse
|
102
|
Iordanova B, Li L, Clark RSB, Manole MD. Alterations in Cerebral Blood Flow after Resuscitation from Cardiac Arrest. Front Pediatr 2017; 5:174. [PMID: 28861407 PMCID: PMC5561008 DOI: 10.3389/fped.2017.00174] [Citation(s) in RCA: 55] [Impact Index Per Article: 7.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/15/2017] [Accepted: 07/28/2017] [Indexed: 01/07/2023] Open
Abstract
Greater than 50% of patients successfully resuscitated from cardiac arrest have evidence of neurological disability. Numerous studies in children and adults, as well as in animal models have demonstrated that cerebral blood flow (CBF) is impaired after cardiac arrest. Stages of cerebral perfusion post-resuscitation include early hyperemia, followed by hypoperfusion, and finally either resolution of normal blood flow or protracted hyperemia. At the level of the microcirculation the blood flow is heterogeneous, with areas of no flow, low flow, and increased flow. CBF directed therapies in animal models of cardiac arrest improved neurological outcome, and therefore, the alterations in CBF after cardiac arrest likely contribute to the development of hypoxic ischemic encephalopathy. Current intensive care after cardiac arrest is centered upon maintaining systemic oxygenation, normal blood pressure values for age, maintaining general homeostasis, and avoiding hyperthermia. Assessment of CBF and oxygenation is not routinely performed after cardiac arrest. Currently available and underutilized techniques to assess cerebral perfusion include transcranial doppler, near-infrared spectroscopy, and arterial spin labeling magnetic resonance imaging. Limited clinical studies established the role of CBF and oxygenation monitoring in prognostication after cardiac arrest and few studies suggest that guiding critical care post-resuscitation to mean arterial pressures above the minimal autoregulatory range might improve outcome. Important knowledge gaps thus remain in cerebral monitoring and CBF and oxygen goal-directed therapies post-resuscitation from cardiac arrest.
Collapse
Affiliation(s)
- Bistra Iordanova
- Department of Bioengineering, University of Pittsburgh, Pittsburgh, PA, United States
| | - Lingjue Li
- School of Pharmacy, University of Pittsburgh, Pittsburgh, PA, United States
| | - Robert S B Clark
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States.,Safar Center for Resuscitation Research, Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA, United States
| | - Mioara D Manole
- Safar Center for Resuscitation Research, Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA, United States
| |
Collapse
|
103
|
Lee JK, Poretti A, Perin J, Huisman TAGM, Parkinson C, Chavez-Valdez R, O'Connor M, Reyes M, Armstrong J, Jennings JM, Gilmore MM, Koehler RC, Northington FJ, Tekes A. Optimizing Cerebral Autoregulation May Decrease Neonatal Regional Hypoxic-Ischemic Brain Injury. Dev Neurosci 2016; 39:248-256. [PMID: 27978510 DOI: 10.1159/000452833] [Citation(s) in RCA: 51] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2016] [Accepted: 10/24/2016] [Indexed: 12/14/2022] Open
Abstract
BACKGROUND Therapeutic hypothermia provides incomplete neuroprotection for neonatal hypoxic-ischemic encephalopathy (HIE). We examined whether hemodynamic goals that support autoregulation are associated with decreased brain injury and whether these relationships are affected by birth asphyxia or vary by anatomic region. METHODS Neonates cooled for HIE received near-infrared spectroscopy autoregulation monitoring to identify the mean arterial blood pressure with optimized autoregulatory function (MAPOPT). Blood pressure deviation from MAPOPT was correlated with brain injury on MRI after adjusting for the effects of arterial carbon dioxide, vasopressors, seizures, and birth asphyxia severity. RESULTS Blood pressure deviation from MAPOPT related to neurologic injury in several regions independent of birth asphyxia severity. Greater duration and deviation of blood pressure below MAPOPT were associated with greater injury in the paracentral gyri and white matter. Blood pressure within MAPOPT related to lesser injury in the white matter, putamen and globus pallidus, and brain stem. Finally, blood pressures that exceeded MAPOPT were associated with reduced injury in the paracentral gyri. CONCLUSIONS Blood pressure deviation from optimal autoregulatory vasoreactivity was associated with MRI markers of brain injury that, in many regions, were independent of the initial birth asphyxia. Targeting hemodynamic ranges to optimize autoregulation has potential as an adjunctive therapy to hypothermia for HIE.
Collapse
Affiliation(s)
- Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
104
|
Tsalach A, Ratner E, Lokshin S, Silman Z, Breskin I, Budin N, Kamar M. Cerebral Autoregulation Real-Time Monitoring. PLoS One 2016; 11:e0161907. [PMID: 27571474 PMCID: PMC5003385 DOI: 10.1371/journal.pone.0161907] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/22/2016] [Accepted: 08/12/2016] [Indexed: 11/19/2022] Open
Abstract
Cerebral autoregulation is a mechanism which maintains constant cerebral blood flow (CBF) despite changes in mean arterial pressure (MAP). Assessing whether this mechanism is intact or impaired and determining its boundaries is important in many clinical settings, where primary or secondary injuries to the brain may occur. Herein we describe the development of a new ultrasound tagged near infra red light monitor which tracks CBF trends, in parallel, it continuously measures blood pressure and correlates them to produce a real time autoregulation index. Its performance is validated in both in-vitro experiment and a pre-clinical case study. Results suggest that using such a tool, autoregulation boundaries as well as its impairment or functioning can be identified and assessed. It may therefore assist in individualized MAP management to ensure adequate organ perfusion and reduce the risk of postoperative complications, and might play an important role in patient care.
Collapse
Affiliation(s)
- Adi Tsalach
- Ornim Medical Ltd, Kfar Saba, Israel
- * E-mail:
| | | | | | | | | | | | | |
Collapse
|
105
|
Addison PS, Antunes A, Montgomery D, Borg UR. Gradient adjustment method for better discriminating correlating and non-correlating regions of physiological signals: application to the partitioning of impaired and intact zones of cerebral autoregulation. J Clin Monit Comput 2016; 31:727-737. [PMID: 27496051 PMCID: PMC5500687 DOI: 10.1007/s10877-016-9913-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/25/2016] [Indexed: 11/10/2022]
Abstract
Cerebral blood flow (CBF) is regulated over a range of systemic blood pressures by the cerebral autoregulation (CA) control mechanism. This range lies within the lower and upper limits of autoregulation (LLA, ULA), beyond which blood pressure drives CBF, and CA function is considered impaired. A standard method to determine autoregulation limits noninvasively using NIRS technology is via the COx measure: a moving correlation index between mean arterial pressure and regional oxygen saturation. In the intact region, there should be no correlation between these variables whereas in the impaired region, the correlation index should approximate unity. In practice, however, the data may be noisy and/or the intact region may often exhibit a slightly positive relationship. This positive relationship may render traditional autoregulation limit calculations difficult to perform, resulting in the need for manual interpretation of the data using arbitrary thresholds. Further, the underlying mathematics of the technique are asymmetric in terms of the results produced for impaired and intact regions and are, in fact, not computable for the ideal case within the intact region. In this work, we propose a novel gradient adjustment method (GACOx) to enhance the differences in COx values observed in the intact and impaired regions. Results from a porcine model (N = 8) are used to demonstrate that GACOx is successful in determining LLA values where traditional methods fail. It is shown that the derived GACOx indices exhibit a mean difference between the intact/impaired regions of 1.54 ± 0.26 (mean ± SD), compared to 0.14 ± 0.10 for the traditional COx method. The GACOx effectively polarizes the COx data in order to better differentiate the intact and impaired zones and, in doing so, makes the determination of the LLA and ULA points a simpler and more consistent task. The method lends itself to the automation of the robust determination of autoregulation zone limits.
Collapse
Affiliation(s)
- Paul S Addison
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK.
| | - André Antunes
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK
| | - Dean Montgomery
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK
| | - Ulf R Borg
- Medtronic Respiratory and Monitoring Solutions, Boulder, CO, USA
| |
Collapse
|
106
|
Noninvasive methods of detecting increased intracranial pressure. Childs Nerv Syst 2016; 32:1371-86. [PMID: 27351182 DOI: 10.1007/s00381-016-3143-x] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Accepted: 06/05/2016] [Indexed: 12/26/2022]
Abstract
The detection of elevated intracranial pressure (ICP) is of paramount importance in the diagnosis and management of a number of neurologic pathologies. The current gold standard is the use of intraventricular or intraparenchymal catheters; however, this is invasive, expensive, and requires anesthesia. On the other hand, diagnosing intracranial hypertension based on clinical symptoms such as headaches, vomiting, and visual changes lacks sensitivity. As such, there exists a need for a noninvasive yet accurate and reliable method for detecting elevated ICP. In this review, we aim to cover both structural modalities such as computed tomography (CT), magnetic resonance imaging (MRI), ocular ultrasound, fundoscopy, and optical coherence tomography (OCT) as well as functional modalities such as transcranial Doppler ultrasound (TCD), visual evoked potentials (VEPs), and near-infrared spectroscopy (NIRS).
Collapse
|
107
|
Fantini S, Sassaroli A, Tgavalekos KT, Kornbluth J. Cerebral blood flow and autoregulation: current measurement techniques and prospects for noninvasive optical methods. NEUROPHOTONICS 2016; 3:031411. [PMID: 27403447 PMCID: PMC4914489 DOI: 10.1117/1.nph.3.3.031411] [Citation(s) in RCA: 216] [Impact Index Per Article: 27.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 01/04/2016] [Accepted: 05/10/2016] [Indexed: 05/23/2023]
Abstract
Cerebral blood flow (CBF) and cerebral autoregulation (CA) are critically important to maintain proper brain perfusion and supply the brain with the necessary oxygen and energy substrates. Adequate brain perfusion is required to support normal brain function, to achieve successful aging, and to navigate acute and chronic medical conditions. We review the general principles of CBF measurements and the current techniques to measure CBF based on direct intravascular measurements, nuclear medicine, X-ray imaging, magnetic resonance imaging, ultrasound techniques, thermal diffusion, and optical methods. We also review techniques for arterial blood pressure measurements as well as theoretical and experimental methods for the assessment of CA, including recent approaches based on optical techniques. The assessment of cerebral perfusion in the clinical practice is also presented. The comprehensive description of principles, methods, and clinical requirements of CBF and CA measurements highlights the potentially important role that noninvasive optical methods can play in the assessment of neurovascular health. In fact, optical techniques have the ability to provide a noninvasive, quantitative, and continuous monitor of CBF and autoregulation.
Collapse
Affiliation(s)
- Sergio Fantini
- Tufts University, Department of Biomedical Engineering, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Angelo Sassaroli
- Tufts University, Department of Biomedical Engineering, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Kristen T. Tgavalekos
- Tufts University, Department of Biomedical Engineering, 4 Colby Street, Medford, Massachusetts 02155, United States
| | - Joshua Kornbluth
- Tufts University School of Medicine, Department of Neurology, Division of Neurocritical Care, 800 Washington Street, Box #314, Boston, Massachusetts 02111, United States
| |
Collapse
|
108
|
Nusbaum DM, Brady KM, Kibler KK, Blaine Easley R. Acute hypercarbia increases the lower limit of cerebral blood flow autoregulation in a porcine model. Neurol Res 2016; 38:196-204. [DOI: 10.1179/1743132815y.0000000094] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
109
|
Brady K, Andropoulos DB, Kibler K, Easley RB. A New Monitor of Pressure Autoregulation: What Does It Add? Anesth Analg 2016; 121:1121-3. [PMID: 26484451 DOI: 10.1213/ane.0000000000000952] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Affiliation(s)
- Ken Brady
- From the Department of Anesthesiology, Baylor College of Medicine, Houston, Texas
| | | | | | | |
Collapse
|
110
|
Kenney K, Amyot F, Haber M, Pronger A, Bogoslovsky T, Moore C, Diaz-Arrastia R. Cerebral Vascular Injury in Traumatic Brain Injury. Exp Neurol 2016; 275 Pt 3:353-366. [DOI: 10.1016/j.expneurol.2015.05.019] [Citation(s) in RCA: 155] [Impact Index Per Article: 19.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2015] [Revised: 05/19/2015] [Accepted: 05/26/2015] [Indexed: 12/14/2022]
|
111
|
Abstract
Pressure autoregulation is an important hemodynamic mechanism that protects the brain against inappropriate fluctuations in cerebral blood flow in the face of changing cerebral perfusion pressure (CPP). Static autoregulation represents how far cerebrovascular resistance changes when CPP varies, and dynamic autoregulation represents how fast these changes happen. Both have been monitored in the setting of neurocritical care to aid prognostication and contribute to individualizing CPP targets in patients. Failure of autoregulation is associated with a worse outcome in various acute neurological diseases. Several studies have used transcranial Doppler ultrasound, intracranial pressure (ICP with vascular reactivity as surrogate measure of autoregulation), and near-infrared spectroscopy to continuously monitor the impact of spontaneous fluctuations in CPP on cerebrovascular physiology and to calculate derived variables of autoregulatory efficiency. Many patients who undergo such monitoring demonstrate a range of CPP in which autoregulatory efficiency is optimal. Management of patients at or near this optimal level of CPP is associated with better outcomes in traumatic brain injury. Many of these studies have utilized the concept of the pressure reactivity index, a correlation coefficient between ICP and mean arterial pressure. While further studies are needed, these data suggest that monitoring of autoregulation could aid prognostication and may help identify optimal CPP levels in individual patients.
Collapse
Affiliation(s)
- Marek Czosnyka
- Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Addenbrooke's Hospital, Box 167, Cambridge, CB2 2QQ, UK,
| | | | | |
Collapse
|
112
|
Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015; 15:209. [PMID: 26486728 PMCID: PMC4618147 DOI: 10.1186/s12883-015-0464-4] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2015] [Accepted: 10/06/2015] [Indexed: 11/17/2022] Open
Abstract
Background Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. Methods In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21–32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. Results Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21–32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. Conclusion In this pilot cohort, motor and cognitive impairments at 21–32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates’ MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE. Electronic supplementary material The online version of this article (doi:10.1186/s12883-015-0464-4) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
113
|
Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883-015-0464-410.1186/s12883-015-0464-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/03/2023] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
Collapse
Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA.
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA.
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
114
|
Burton VJ, Gerner G, Cristofalo E, Chung SE, Jennings JM, Parkinson C, Koehler RC, Chavez-Valdez R, Johnston MV, Northington FJ, Lee JK. A pilot cohort study of cerebral autoregulation and 2-year neurodevelopmental outcomes in neonates with hypoxic-ischemic encephalopathy who received therapeutic hypothermia. BMC Neurol 2015. [PMID: 26486728 DOI: 10.1186/s12883‐015‐0464‐4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Neurodevelopmental disabilities persist in survivors of neonatal hypoxic-ischemic encephalopathy (HIE) despite treatment with therapeutic hypothermia. Cerebrovascular autoregulation, the mechanism that maintains cerebral perfusion during changes in blood pressure, may influence outcomes. Our objective was to describe the relationship between acute autoregulatory vasoreactivity during treatment and neurodevelopmental outcomes at 2 years of age. METHODS In a pilot study of 28 neonates with HIE, we measured cerebral autoregulatory vasoreactivity with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The HVx, which is derived from near-infrared spectroscopy, was used to identify the individual optimal mean arterial blood pressure (MAPOPT) at which autoregulatory vasoreactivity is greatest. Cognitive and motor neurodevelopmental evaluations were completed in 19 children at 21-32 months of age. MAPOPT, blood pressure in relation to MAPOPT, blood pressure below gestational age + 5 (ga + 5), and regional cerebral oximetry (rSO2) were compared to the neurodevelopmental outcomes. RESULTS Nineteen children who had HIE and were treated with therapeutic hypothermia performed in the average range on cognitive and motor evaluations at 21-32 months of age, although the mean performance was lower than that of published normative samples. Children with impairments at the 2-year evaluation had higher MAPOPT values, spent more time with blood pressure below MAPOPT, and had greater blood pressure deviation below MAPOPT during rewarming in the neonatal period than those without impairments. Greater blood pressure deviation above MAPOPT during rewarming was associated with less disability and higher cognitive scores. No association was observed between rSO2 or blood pressure below ga + 5 and neurodevelopmental outcomes. CONCLUSION In this pilot cohort, motor and cognitive impairments at 21-32 months of age were associated with greater blood pressure deviation below MAPOPT during rewarming following therapeutic hypothermia, but not with rSO2 or blood pressure below ga + 5. This suggests that identifying individual neonates' MAPOPT is superior to using hemodynamic goals based on gestational age or rSO2 in the acute management of neonatal HIE.
Collapse
Affiliation(s)
- Vera Joanna Burton
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology and Developmental Medicine, Kennedy Krieger Institute, Johns Hopkins School of Medicine, 801 N Broadway, Baltimore, MD, 21205, USA.
| | - Gwendolyn Gerner
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neuropsychology, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Elizabeth Cristofalo
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Shang-en Chung
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jacky M Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Michael V Johnston
- Neurology and Developmental Medicine, Kennedy Krieger Institute, Baltimore, MD, USA. .,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Neurology, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Hugo Moser Research Institute, Kennedy Krieger Institute, Baltimore, MD, USA.
| | - Frances J Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Division of Perinatal-Neonatal Medicine, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| | - Jennifer K Lee
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD, USA. .,Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD, USA.
| |
Collapse
|
115
|
Kim N, Krasner A, Kosinski C, Wininger M, Qadri M, Kappus Z, Danish S, Craelius W. Trending autoregulatory indices during treatment for traumatic brain injury. J Clin Monit Comput 2015; 30:821-831. [PMID: 26446002 DOI: 10.1007/s10877-015-9779-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 09/22/2015] [Indexed: 12/14/2022]
Abstract
Our goal is to use automatic data monitoring for reliable prediction of episodes of intracranial hypertension in patients with traumatic brain injury. Here we test the validity of our method on retrospective patient data. We developed the Continuous Hemodynamic Autoregulatory Monitor (CHARM), that siphons and stores signals from existing monitors in the surgical intensive care unit (SICU), efficiently compresses them, and standardizes the search for statistical relationships between any proposed index and adverse events. CHARM uses an automated event detector to reliably locate episodes of elevated intracranial pressure (ICP), while eliminating artifacts within retrospective patient data. A graphical user interface allowed data scanning, selection of criteria for events, and calculating indices. The pressure reactivity index (PRx), defined as the least square linear regression slope of intracranial pressure versus arterial BP, was calculated for a single case that spanned 259 h. CHARM collected continuous records of ABP, ICP, ECG, SpO2, and ventilation from 29 patients with TBI over an 18-month period. Analysis of a single patient showed that PRx data distribution in the single hours immediately prior to all 16 intracranial hypertensive events, significantly differed from that in the 243 h that did not precede such events (p < 0.0001). The PRx index, however, lacked sufficient resolution as a real-time predictor of IH in this patient. CHARM streamlines the search for reliable predictors of intracranial hypertension. We report statistical evidence supporting the predictive potential of the pressure reactivity index.
Collapse
Affiliation(s)
- Nam Kim
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Alex Krasner
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Colin Kosinski
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Michael Wininger
- Rehabilitation Sciences, University of Hartford, West Hartford, CT, 06117, USA
| | - Maria Qadri
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Zachary Kappus
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Shabbar Danish
- Department of Neurosurgery, Rutgers Cancer Institute, Rutgers-RWJ Medical School, New Brunswick, NJ, 08901, USA
| | - William Craelius
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA.
| |
Collapse
|
116
|
Highton D, Ghosh A, Tachtsidis I, Panovska-Griffiths J, Elwell CE, Smith M. Monitoring cerebral autoregulation after brain injury: multimodal assessment of cerebral slow-wave oscillations using near-infrared spectroscopy. Anesth Analg 2015; 121:198-205. [PMID: 25993387 DOI: 10.1213/ane.0000000000000790] [Citation(s) in RCA: 46] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Continuous monitoring of cerebral autoregulation might provide novel treatment targets and identify therapeutic windows after acute brain injury. Slow oscillations of cerebral hemodynamics (0.05-0.003 Hz) are visible in multimodal neuromonitoring and may be analyzed to provide novel, surrogate measures of autoregulation. Near-infrared spectroscopy (NIRS) is an optical neuromonitoring technique, which shows promise for widespread clinical applicability because it is noninvasive and easily delivered across a wide range of clinical scenarios. The aim of this study is to identify the relationship between NIRS signal oscillations and multimodal neuromonitoring, examining the utility of near infrared derived indices of cerebrovascular reactivity. METHODS Twenty-seven sedated, ventilated, brain-injured patients were included in this observational study. Intracranial pressure, transcranial Doppler-derived flow velocity in the middle cerebral artery, and ipsilateral cerebral NIRS variables were continuously monitored. Signals were compared using wavelet measures of phase and coherence to examine the spectral features involved in reactivity index calculations. Established indices of autoregulatory reserve such as the pressure reactivity index (PRx) and mean velocity index (Mx) and the NIRS indices such as total hemoglobin reactivity index (THx) and tissue oxygen reactivity index (TOx) were compared using correlation and Bland-Altman analysis. RESULTS NIRS indices correlated significantly between PRx and THx (rs = 0.63, P < 0.001), PRx and TOx (r = 0.40, P = 0.04), and Mx and TOx (r = 0.61, P = 0.004) but not between Mx and THx (rs = 0.26, P = 0.28) and demonstrated wide limits between these variables: PRx and THx (bias, -0.06; 95% limits, -0.44 to 0.32) and Mx and TOx (bias, +0.15; 95% limits, -0.34 to 0.64). Analysis of slow-wave activity throughout the intracranial pressure, transcranial Doppler, and NIRS recordings revealed statistically significant interrelationships, which varied dynamically and were nonsignificant at frequencies <0.008 Hz. CONCLUSIONS Although slow-wave activity in intracranial pressure, transcranial Doppler, and NIRS is significantly similar, it varies dynamically in both time and frequency, and this manifests as incomplete agreement between reactivity indices. Analysis informed by a priori knowledge of physiology underpinning NIRS variables combined with sophisticated analysis techniques has the potential to deliver noninvasive surrogate measures of autoregulation, guiding therapy.
Collapse
Affiliation(s)
- David Highton
- From the Department of Neurocritical Care, National Hospital for Neurology and Neurosurgery, University College London Hospitals NHS Trust, London, United Kingdom; and the Department of Medical Physics and Bioengineering, University College London, London, United Kingdom
| | | | | | | | | | | |
Collapse
|
117
|
Addison PS. A Review of Wavelet Transform Time-Frequency Methods for NIRS-Based Analysis of Cerebral Autoregulation. IEEE Rev Biomed Eng 2015; 8:78-85. [PMID: 26011892 DOI: 10.1109/rbme.2015.2436978] [Citation(s) in RCA: 27] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Near-infrared spectroscopy (NIRS) has been proposed as a suitable technique for the analysis of cerebral autoregulation as it provides a simpler acquisition methodology and more artifact-free signal. A number of sophisticated wavelet transform methods have recently emerged to quantify the cerebral autoregulation mechanism using NIRS and blood pressure signals. These provide an enhanced partitioning of signal information via the time-frequency plane, which facilitates improved extraction of the components of interest. This area is reviewed, and enhancements to this form of analysis are suggested.
Collapse
|
118
|
An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: time to drop 'one-size-fits-all' hemodynamic targets? Resuscitation 2015; 90:121-6. [PMID: 25769511 DOI: 10.1016/j.resuscitation.2015.03.001] [Citation(s) in RCA: 94] [Impact Index Per Article: 10.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/11/2015] [Revised: 02/24/2015] [Accepted: 03/01/2015] [Indexed: 11/23/2022]
Abstract
AIMS A subgroup of patients with ROSC after cardiac arrest (CA) with disturbed cerebral autoregulation might benefit from higher mean arterial pressures (MAP). We aimed to (1) phenotype patients with disturbed autoregulation, (2) investigate whether these patients have a worse prognosis, (3) define an individual optimal MAP per patient and (4) investigate whether time under this individual optimal MAP is associated with outcome. METHODS Prospective observational study in 51 post-CA patients monitored with near infrared spectroscopy. RESULTS (1) 18/51 patients (35%) had disturbed autoregulation. Phenotypically, a higher proportion of patients with disturbed autoregulation had pre-CA hypertension (31±47 vs. 65±49%, p=0.02) suggesting that right shifting of autoregulation is caused by chronic adaptation of cerebral blood flow to higher blood pressures. (2) In multivariate analysis, patients with preserved autoregulation (n=33, 65%) had a significant higher 180-days survival rate (OR 4.62, 95% CI [1.06:20.06], p=0.04]. Based on an index of autoregulation (COX), the average COX-predicted optimal MAP was 85 mmHg in patients with preserved and 100 mmHg in patients with disturbed autoregulation. (3) An individual optimal MAP could be determined in 33/51 patients. (4) The time under the individual optimal MAP was negatively associated with survival (OR 0.97, 95% CI [0.96:0.99], p=0.02). The time under previously proposed fixed targets (65, 70, 75, 80 mmHg) was not associated with a differential survival rate. CONCLUSION Cerebral autoregulation showed to be disturbed in 35% of post-CA patients of which a majority had pre-CA hypertension. Disturbed cerebral autoregulation within the first 24h after CA is associated with a worse outcome. In contrast to uniform MAP goals, the time spent under a patient tailored optimal MAP, based on an index of autoregulation, was negatively associated with survival.
Collapse
|
119
|
Jindal U, Sood M, Dutta A, Chowdhury SR. Development of Point of Care Testing Device for Neurovascular Coupling From Simultaneous Recording of EEG and NIRS During Anodal Transcranial Direct Current Stimulation. IEEE JOURNAL OF TRANSLATIONAL ENGINEERING IN HEALTH AND MEDICINE 2015; 3:2000112. [PMID: 27170897 PMCID: PMC4848058 DOI: 10.1109/jtehm.2015.2389230] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/08/2014] [Revised: 09/06/2014] [Accepted: 12/18/2014] [Indexed: 01/17/2023]
Abstract
This paper presents a point of care testing device for neurovascular coupling (NVC) from simultaneous recording of electroencephalogram (EEG) and near infrared spectroscopy (NIRS) during anodal transcranial direct current stimulation (tDCS). Here, anodal tDCS modulated cortical neural activity leading to hemodynamic response can be used to identify the impaired cerebral microvessels functionality. The impairments in the cerebral microvessels functionality may lead to impairments in the cerebrovascular reactivity (CVR), where severely reduced CVR predicts the chances of transient ischemic attack and ipsilateral stroke. The neural and hemodynamic responses to anodal tDCS were studied through joint imaging with EEG and NIRS, where NIRS provided optical measurement of changes in tissue oxy-([Formula: see text] and deoxy-([Formula: see text]) hemoglobin concentration and EEG captured alterations in the underlying neuronal current generators. Then, a cross-correlation method for the assessment of NVC underlying the site of anodal tDCS is presented. The feasibility studies on healthy subjects and stroke survivors showed detectable changes in the EEG and the NIRS responses to a 0.526 A/[Formula: see text] of anodal tDCS. The NIRS system was bench tested on 15 healthy subjects that showed a statistically significant (p < 0.01) difference in the signal-to-noise ratio (SNR) between the ON- and OFF-states of anodal tDCS where the mean SNR of the NIRS device was found to be 42.33 ± 1.33 dB in the ON-state and 40.67 ± 1.23 dB in the OFF-state. Moreover, the clinical study conducted on 14 stroke survivors revealed that the lesioned hemisphere with impaired circulation showed significantly (p < 0.01) less change in [Formula: see text] than the nonlesioned side in response to anodal tDCS. The EEG study on healthy subjects showed a statistically significant (p < 0.05) decrease around individual alpha frequency in the alpha band (8-13 Hz) following anodal tDCS. Moreover, the joint EEG-NIRS imaging on 4 stroke survivors showed an immediate increase in the theta band (4-8 Hz) EEG activity after the start of anodal tDCS at the nonlesioned hemisphere. Furthermore, cross-correlation function revealed a significant (95% confidence interval) negative cross correlation only at the nonlesioned hemisphere during anodal tDCS, where the log-transformed mean-power of EEG within 0.5-11.25 Hz lagged [Formula: see text] response in one of the stroke survivors with white matter lesions. Therefore, it was concluded that the anodal tDCS can perturb the local neural and the vascular activity (via NVC) which can be used for assessing regional NVC functionality where confirmatory clinical studies are required.
Collapse
Affiliation(s)
- Utkarsh Jindal
- Centre for VLSI and Embedded Systems TechnologyInternational Institute of Information Technology HyderabadHyderabad500032India
| | - Mehak Sood
- Centre for VLSI and Embedded Systems TechnologyInternational Institute of Information Technology HyderabadHyderabad500032India
| | - Anirban Dutta
- Institut national de recherche en informatique et en automatiqueMontpellier34095France
| | - Shubhajit Roy Chowdhury
- Centre for VLSI and Embedded Systems TechnologyInternational Institute of Information Technology HyderabadHyderabad500032India
| |
Collapse
|
120
|
An Update on Cerebral Oxygenation Monitoring, an Innovative Application in Cardiac Arrest and Neurological Emergencies. ACTA ACUST UNITED AC 2015. [DOI: 10.1007/978-3-319-13761-2_20] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register]
|
121
|
Rhee CJ, Fraser CD, Kibler K, Easley RB, Andropoulos DB, Czosnyka M, Varsos GV, Smielewski P, Rusin CG, Brady KM, Kaiser JR. The ontogeny of cerebrovascular pressure autoregulation in premature infants. J Perinatol 2014; 34:926-31. [PMID: 25010225 PMCID: PMC4383263 DOI: 10.1038/jp.2014.122] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/04/2013] [Revised: 04/01/2014] [Accepted: 05/16/2014] [Indexed: 11/10/2022]
Abstract
OBJECTIVE To quantify cerebrovascular autoregulation as a function of gestational age (GA) and across the phases of the cardiac cycle. STUDY DESIGN The present study is a hypothesis-generating re-analysis of previously published data. Premature infants (n=179) with a GA range of 23 to 33 weeks were monitored with umbilical artery catheters and transcranial Doppler insonation of the middle cerebral artery for 1-h sessions over the first week of life. Autoregulation was quantified by three methods, as a moving correlation coefficient between: (1) systolic arterial blood pressure (ABP) and systolic cerebral blood flow (CBF) velocity (Sx); (2) mean ABP and mean CBF velocity (Mx); and (3) diastolic ABP and diastolic CBF velocity (Dx). Comparisons of individual and cohort cerebrovascular pressure autoregulation were made across GA for each aspect of the cardiac cycle. RESULTS Systolic, mean and diastolic ABP increased with GA (r=0.3, 0.4 and 0.4; P<0.0001). Systolic CBF velocity was pressure-passive in infants with the lowest GA, and Sx decreased with advancing GA (r=-0.3; P<0.001), indicating increased capacity for cerebral autoregulation during systole during development. By contrast, Dx was elevated, indicating dysautoregulation, in all subjects and showed minimal change with advancing GA (r=-0.06; P=0.05). Multivariate analysis confirmed that both GA (P<0.001) and 'effective cerebral perfusion pressure' (ABP minus critical closing pressure (CrCP); P<0.01) were associated with Sx. CONCLUSION Premature infants have low and usually pressure-passive diastolic CBF velocity. By contrast, the regulation of systolic CBF velocity by pressure autoregulation developed in this cohort between 23 and 33 weeks GA. Elevated effective cerebral perfusion pressure derived from the CrCP was associated with dysautoregulation.
Collapse
Affiliation(s)
- Christopher J. Rhee
- Department of Pediatrics, Section of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | | | - Kathleen Kibler
- Departments of Pediatrics and Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ronald B. Easley
- Departments of Pediatrics and Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Dean B. Andropoulos
- Departments of Pediatrics and Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Marek Czosnyka
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge University, Cambridge, England
| | - Georgios V. Varsos
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge University, Cambridge, England
| | - Peter Smielewski
- Division of Neurosurgery, Addenbrooke’s Hospital, Cambridge University, Cambridge, England
| | - Craig G. Rusin
- Department of Cardiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Ken M. Brady
- Departments of Pediatrics and Anesthesiology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| | - Jeffrey R. Kaiser
- Departments of Pediatrics and Obstetrics and Gynecology, Section of Neonatology, Texas Children’s Hospital, Baylor College of Medicine, Houston, TX, USA
| |
Collapse
|
122
|
Molinari F, Simonetti V, Franzini M, Pandolfi S, Vaiano F, Valdenassi L, Liboni W. Ozone autohemotherapy induces long-term cerebral metabolic changes in multiple sclerosis patients. Int J Immunopathol Pharmacol 2014; 27:379-89. [PMID: 25280029 DOI: 10.1177/039463201402700308] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022] Open
Abstract
Ozone autohemotherapy is an emerging therapeutic technique that is gaining increasing importance in treating neurological disorders. A validated and standard methodology to assess the effect of such therapy on brain metabolism and circulation is however still lacking. We used a near-infrared spectroscopy (NIRS) system to monitor the cerebral metabolism and a transcranial Doppler (TCD) to monitor the blood flow velocity in the middle cerebral arteries. Fifty-four subjects (32 neurological patients and 22 controls) were tested before, during, and after ozone autohemotherapy. We monitored the concentration changes in the level of oxygenated and deoxygenated haemoglobin, and in the level of the Cytochrome-c-oxidase (CYT-c). As a primary endpoint of the work, we showed the changes in the brain metabolism and circulation of the entire population. The concentration of oxygenated haemoglobin increased after the reinjection of the ozoned blood and remained higher than the beginning for another 1.5 hours. The concentration of the deoxygenated haemoglobin decreased during the therapy and the CYT-c concentration markedly increased about 1 hour after the reinjection. No significant changes were observed on the blood flow velocity. As secondary endpoint, we compared the NIRS metabolic pattern of 20 remitting-relapsing multiple sclerosis (MS) patients against 20 controls. We showed that by using only 7 NIRS variables it was possible to characterize the metabolic brain pattern of the two groups of subjects. The MS subjects showed a marked increase of the CYT-c activity and concentration about 40 minutes after the end of the autohemotherapy, possibly revealing a reduction of the chronic oxidative stress level typical of MS sufferers. From a technical point of view, this preliminary study showed that NIRS could be useful to show the effects of ozone autohemotherapy at cerebral level, in a long-term monitoring. The clinical result of this study is the quantitative measurement of the CYT-c level changes in MS induced by ozone autohemotherapy.
Collapse
Affiliation(s)
- F Molinari
- Biolab, Department of Electronics and Telecommunications, Politecnico di Torino, Torino, Italy
| | | | - M Franzini
- Italian Society for Oxygen and Ozone Therapy, Bergamo, Italy
| | - S Pandolfi
- Italian Society for Oxygen and Ozone Therapy, Bergamo, Italy
| | - F Vaiano
- Italian Society for Oxygen and Ozone Therapy, Bergamo, Italy
| | - L Valdenassi
- Italian Society for Oxygen and Ozone Therapy, Bergamo, Italy
| | - W Liboni
- "Un passo insieme" ONLUS Foundation, Torino, Italy
| |
Collapse
|
123
|
Tekes A, Poretti A, Scheurkogel MM, Huisman TAGM, Howlett JA, Alqahtani E, Lee JH, Parkinson C, Shapiro K, Chung SE, Jennings JM, Gilmore MM, Hogue CW, Martin LJ, Koehler RC, Northington FJ, Lee JK. Apparent diffusion coefficient scalars correlate with near-infrared spectroscopy markers of cerebrovascular autoregulation in neonates cooled for perinatal hypoxic-ischemic injury. AJNR Am J Neuroradiol 2014; 36:188-93. [PMID: 25169927 DOI: 10.3174/ajnr.a4083] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
BACKGROUND AND PURPOSE Neurologic morbidity remains high in neonates with perinatal hypoxic-ischemic injury despite therapeutic hypothermia. DTI provides qualitative and quantitative information about the microstructure of the brain, and a near-infrared spectroscopy index can assess cerebrovascular autoregulation. We hypothesized that lower ADC values would correlate with worse autoregulatory function. MATERIALS AND METHODS Thirty-one neonates with hypoxic-ischemic injury were enrolled. ADC scalars were measured in 27 neonates (age range, 4-15 days) in the anterior and posterior centrum semiovale, basal ganglia, thalamus, posterior limb of the internal capsule, pons, and middle cerebellar peduncle on MRI obtained after completion of therapeutic hypothermia. The blood pressure range of each neonate with the most robust autoregulation was identified by using a near-infrared spectroscopy index. Autoregulatory function was measured by blood pressure deviation below the range with optimal autoregulation. RESULTS In neonates who had MRI on day of life ≥10, lower ADC scalars in the posterior centrum semiovale (r = -0.87, P = .003, n = 9) and the posterior limb of the internal capsule (r = -0.68, P = .04, n = 9) correlated with blood pressure deviation below the range with optimal autoregulation during hypothermia. Lower ADC scalars in the basal ganglia correlated with worse autoregulation during rewarming (r = -0.71, P = .05, n = 8). CONCLUSIONS Blood pressure deviation from the optimal autoregulatory range may be an early biomarker of injury in the posterior centrum semiovale, posterior limb of the internal capsule, and basal ganglia. Optimizing blood pressure to support autoregulation may decrease the risk of brain injury in cooled neonates with hypoxic-ischemic injury.
Collapse
Affiliation(s)
- A Tekes
- From the Division of Pediatric Radiology and Pediatric Neuroradiology (A.T., A.P., M.M.S., T.A.G.M.H., E.A.), Department of Radiology Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.)
| | - A Poretti
- From the Division of Pediatric Radiology and Pediatric Neuroradiology (A.T., A.P., M.M.S., T.A.G.M.H., E.A.), Department of Radiology Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.)
| | - M M Scheurkogel
- From the Division of Pediatric Radiology and Pediatric Neuroradiology (A.T., A.P., M.M.S., T.A.G.M.H., E.A.), Department of Radiology
| | - T A G M Huisman
- From the Division of Pediatric Radiology and Pediatric Neuroradiology (A.T., A.P., M.M.S., T.A.G.M.H., E.A.), Department of Radiology Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.)
| | - J A Howlett
- Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.) Division of Neonatology, (J.A.H., C.P., K.S., M.M.G., F.J.N.), Department of Pediatrics
| | - E Alqahtani
- From the Division of Pediatric Radiology and Pediatric Neuroradiology (A.T., A.P., M.M.S., T.A.G.M.H., E.A.), Department of Radiology
| | - J-H Lee
- Department of Anesthesiology and Critical Care Medicine (J.-H.L., C.W.H., R.C.K.)
| | - C Parkinson
- Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.) Division of Neonatology, (J.A.H., C.P., K.S., M.M.G., F.J.N.), Department of Pediatrics
| | - K Shapiro
- Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.) Division of Neonatology, (J.A.H., C.P., K.S., M.M.G., F.J.N.), Department of Pediatrics
| | - S-E Chung
- Division of General Pediatrics and Adolescent Medicine (S.-E.C., J.M.J.), Department of Pediatrics Center for Child and Community Health Research (S.-E.C., J.M.J., J.K.L.)
| | - J M Jennings
- Division of General Pediatrics and Adolescent Medicine (S.-E.C., J.M.J.), Department of Pediatrics Center for Child and Community Health Research (S.-E.C., J.M.J., J.K.L.)
| | - M M Gilmore
- Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.) Division of Neonatology, (J.A.H., C.P., K.S., M.M.G., F.J.N.), Department of Pediatrics
| | - C W Hogue
- Department of Anesthesiology and Critical Care Medicine (J.-H.L., C.W.H., R.C.K.)
| | - L J Martin
- Division of Neuropathology (L.J.M.), Department of Pathology, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - R C Koehler
- Department of Anesthesiology and Critical Care Medicine (J.-H.L., C.W.H., R.C.K.)
| | - F J Northington
- Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.) Division of Neonatology, (J.A.H., C.P., K.S., M.M.G., F.J.N.), Department of Pediatrics
| | - J K Lee
- Neurosciences Intensive Care Nursery Program (A.T., A.P., T.A.G.M.H, J.A.H., C.P., K.S., M.M.G., F.J.N., J.K.L.) Center for Child and Community Health Research (S.-E.C., J.M.J., J.K.L.)
| |
Collapse
|
124
|
Pesek M, Kibler K, Easley RB, Mytar J, Rhee C, Andropoulos D, Brady K. The Upper Limit of Cerebral Blood Flow Autoregulation Is Decreased With Elevations in Intracranial Pressure. Neurosurgery 2014; 75:163-70; discussion 169-70. [DOI: 10.1227/neu.0000000000000367] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
|
125
|
Lee JK, Brady KM, Chung SE, Jennings JM, Whitaker EE, Aganga D, Easley RB, Heitmiller K, Jamrogowicz JL, Larson AC, Lee JH, Jordan LC, Hogue CW, Lehmann CU, Bembea MM, Hunt EA, Koehler RC, Shaffner DH. A pilot study of cerebrovascular reactivity autoregulation after pediatric cardiac arrest. Resuscitation 2014; 85:1387-93. [PMID: 25046743 DOI: 10.1016/j.resuscitation.2014.07.006] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2013] [Revised: 06/26/2014] [Accepted: 07/07/2014] [Indexed: 11/17/2022]
Abstract
AIM Improved survival after cardiac arrest has placed greater emphasis on neurologic resuscitation. The purpose of this pilot study was to evaluate the relationship between cerebrovascular autoregulation and neurologic outcomes after pediatric cardiac arrest. METHODS Children resuscitated from cardiac arrest had autoregulation monitoring during the first 72h after return of circulation with an index derived from near-infrared spectroscopy in a pilot study. The range of mean arterial blood pressure (MAP) with optimal vasoreactivity (MAPOPT) was identified. The area under the curve (AUC) of the time spent with MAP below MAPOPT and MAP deviation below MAPOPT was calculated. Neurologic outcome measures included placement of a new tracheostomy or gastrostomy, death from a primary neurologic etiology (brain death or withdrawal of support for neurologic futility), and change in the Pediatric Cerebral Performance Category score (ΔPCPC). RESULTS Thirty-six children were monitored. Among children who did not require extracorporeal membrane oxygenation (ECMO), children who received a tracheostomy/gastrostomy had greater AUC during the second 24h after resuscitation than those who did not (P=0.04; n=19). Children without ECMO who died from a neurologic etiology had greater AUC during the first 48h than did those who lived or died from cardiovascular failure (P=0.04; n=19). AUC below MAPOPT was not associated with ΔPCPC when children with or without ECMO were analyzed separately. CONCLUSIONS Deviation from the blood pressure with optimal autoregulatory vasoreactivity may predict poor neurologic outcomes after pediatric cardiac arrest. This experimental autoregulation monitoring technique may help individualize blood pressure management goals after resuscitation.
Collapse
Affiliation(s)
- Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA.
| | - Ken M Brady
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, USA
| | - Shang-En Chung
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU, USA; Center for Child and Community Health Research, JHU, USA
| | - Jacky M Jennings
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU, USA; Center for Child and Community Health Research, JHU, USA
| | - Emmett E Whitaker
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Devon Aganga
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Ronald B Easley
- Department of Anesthesiology, Texas Children's Hospital, Houston, TX, USA
| | - Kerry Heitmiller
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Jessica L Jamrogowicz
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Abby C Larson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Jeong-Hoo Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Lori C Jordan
- Department of Neurology, Vanderbilt University (VU), Nashville, TN, USA
| | - Charles W Hogue
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Christoph U Lehmann
- Department of Pediatrics, VU, USA; Department of Biomedical Informatics, VU, USA
| | - Mela M Bembea
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Elizabeth A Hunt
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Raymond C Koehler
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| | - Donald H Shaffner
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University (JHU), Baltimore, MD, USA
| |
Collapse
|
126
|
Williams M, Lee JK. Intraoperative blood pressure and cerebral perfusion: strategies to clarify hemodynamic goals. Paediatr Anaesth 2014; 24:657-67. [PMID: 24725244 PMCID: PMC4154320 DOI: 10.1111/pan.12401] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 03/06/2014] [Indexed: 01/24/2023]
Abstract
Blood pressure can vary considerably during anesthesia. If blood pressure falls outside the limits of cerebrovascular autoregulation, children can become at risk of cerebral ischemic or hyperemic injury. However, the blood pressure limits of autoregulation are unclear in infants and children, and these limits can shift after brain injury. This article will review autoregulation, considerations for the hemodynamic management of children with brain injuries, and research on autoregulation monitoring techniques.
Collapse
Affiliation(s)
- Monica Williams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, USA
| |
Collapse
|
127
|
Nusbaum D, Clark J, Brady K, Kibler K, Sutton J, Easley RB. Alteration in the lower limit of autoregulation with elevations in cephalic venous pressure. Neurol Res 2014; 36:1063-71. [DOI: 10.1179/1743132814y.0000000397] [Citation(s) in RCA: 17] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
|
128
|
Zweifel C, Dias C, Smielewski P, Czosnyka M. Continuous time-domain monitoring of cerebral autoregulation in neurocritical care. Med Eng Phys 2014; 36:638-45. [DOI: 10.1016/j.medengphy.2014.03.002] [Citation(s) in RCA: 44] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/27/2013] [Revised: 02/24/2014] [Accepted: 03/10/2014] [Indexed: 12/26/2022]
|
129
|
The intensive care management of acute ischemic stroke: an overview. Intensive Care Med 2014; 40:640-53. [DOI: 10.1007/s00134-014-3266-z] [Citation(s) in RCA: 58] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/24/2014] [Accepted: 03/11/2014] [Indexed: 01/21/2023]
|
130
|
Howlett JA, Northington FJ, Gilmore MM, Tekes A, Huisman TA, Parkinson C, Chung SE, Jennings JM, Jamrogowicz JJ, Larson AC, Lehmann CU, Jackson E, Brady KM, Koehler RC, Lee JK. Cerebrovascular autoregulation and neurologic injury in neonatal hypoxic-ischemic encephalopathy. Pediatr Res 2013; 74:525-35. [PMID: 23942555 PMCID: PMC3954983 DOI: 10.1038/pr.2013.132] [Citation(s) in RCA: 89] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/08/2012] [Accepted: 01/31/2013] [Indexed: 12/12/2022]
Abstract
BACKGROUND Neonates with hypoxic-ischemic encephalopathy (HIE) are at risk of cerebral blood flow dysregulation. Our objective was to describe the relationship between autoregulation and neurologic injury in HIE. METHODS Neonates with HIE had autoregulation monitoring with the hemoglobin volume index (HVx) during therapeutic hypothermia, rewarming, and the first 6 h of normothermia. The 5-mm Hg range of mean arterial blood pressure (MAP) with best vasoreactivity (MAPOPT) was identified. The percentage of time spent with MAP below MAPOPT and deviation in MAP from MAPOPT were measured. Neonates received brain magnetic resonance imaging (MRI) 3-7 d after treatment. MRIs were coded as no, mild, or moderate/severe injury in five regions. RESULTS HVx identified MAPOPT in 79% (19/24), 77% (17/22), and 86% (18/21) of the neonates during hypothermia, rewarming, and normothermia, respectively. Neonates with moderate/severe injury in paracentral gyri, white matter, basal ganglia, and thalamus spent a greater proportion of time with MAP below MAPOPT during rewarming than neonates with no or mild injury. Neonates with moderate/severe injury in paracentral gyri, basal ganglia, and thalamus had greater MAP deviation below MAPOPT during rewarming than neonates without injury. CONCLUSION Maintaining MAP within or above MAPOPT may reduce the risk of neurologic injuries in neonatal HIE.
Collapse
Affiliation(s)
- Jessica A. Howlett
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Frances J. Northington
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Maureen M. Gilmore
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Aylin Tekes
- Neurosciences Intensive Care Nursery Program, JHU,Department of Radiology, Division of Pediatric Radiology, JHU
| | - Thierry A.G.M. Huisman
- Neurosciences Intensive Care Nursery Program, JHU,Department of Radiology, Division of Pediatric Radiology, JHU
| | - Charlamaine Parkinson
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD,Neurosciences Intensive Care Nursery Program, JHU
| | - Shang-En Chung
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU,Center for Child and Community Health Research (CCHR), JHU
| | - Jacky M. Jennings
- Department of Pediatrics, Division of General Pediatrics and Adolescent Medicine, JHU,Center for Child and Community Health Research (CCHR), JHU
| | | | - Abby C. Larson
- Department of Anesthesiology and Critical Care Medicine, JHU
| | - Christoph U. Lehmann
- Department of Pediatrics, Division of Neonatology, Johns Hopkins University School of Medicine (JHU), Baltimore, MD
| | - Eric Jackson
- Department of Anesthesiology and Critical Care Medicine, JHU
| | - Ken M. Brady
- Department of Anesthesiology, Texas Children’s Hospital, Houston, TX
| | | | - Jennifer K. Lee
- Neurosciences Intensive Care Nursery Program, JHU,Department of Anesthesiology and Critical Care Medicine, JHU
| |
Collapse
|
131
|
Blaine Easley R, Kibler KK, Brady KM, Joshi B, Ono M, Brown C, Hogue CW. Continuous cerebrovascular reactivity monitoring and autoregulation monitoring identify similar lower limits of autoregulation in patients undergoing cardiopulmonary bypass. Neurol Res 2013; 35:344-54. [PMID: 23540403 DOI: 10.1179/1743132812y.0000000145] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES Cerebrovascular autoregulation can be monitored with a moving linear correlation of blood pressure to cerebral blood flow velocity (mean velocity index, Mx) during cardiopulmonary bypass (CPB). Vascular reactivity can be monitored with a moving linear correlation of blood pressure to cerebral blood volume trended with near-infrared spectroscopy (hemoglobin volume index, HVx). We hypothesized that the lower limits of autoregulation (LLA) and the optimal blood pressure (ABPopt) associated with the most active autoregulation could be determined by HVx in patients undergoing CPB. METHODS Adult patients (n = 109) who underwent CPB for cardiac surgery had monitoring of both autoregulation (Mx) and vascular reactivity (HVx). Individual curves of Mx and HVx were constructed by placing each in 5 mmHg bins. The LLA and ABPopt for each subject were then identified by both methods and compared for agreement by correlation analysis and Bland-Altman. RESULTS The average LLA defined by Mx compared to HVx were comparable (66±13 and 66±12 mmHg). Correlation between the LLA defined by Mx and HVx was significant (Pearson r = 0.2867; P = 0.0068). The average ABPopt with the most robust autoregulation by Mx was comparable to HVx (75±11 and 74±13 mmHg) with significant correlation (Pearson r = 0.5915; P < or =0.0001). DISCUSSION Autoregulation and vascular reactivity monitoring are expected to be distinct, as flow and volume have different phasic relationships to pressure when cerebrovascular autoregulation is active. However, the two metrics have good agreement when identifying the LLA and optimal blood pressure in patients during CPB.
Collapse
Affiliation(s)
- R Blaine Easley
- Baylor College of Medicine, Texas Children's Hospital, Houston, TX 77030, USA.
| | | | | | | | | | | | | |
Collapse
|
132
|
Larson AC, Jamrogowicz JL, Kulikowicz E, Wang B, Yang ZJ, Shaffner DH, Koehler RC, Lee JK. Cerebrovascular autoregulation after rewarming from hypothermia in a neonatal swine model of asphyxic brain injury. J Appl Physiol (1985) 2013; 115:1433-42. [PMID: 24009008 DOI: 10.1152/japplphysiol.00238.2013] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
After hypoxic brain injury, maintaining blood pressure within the limits of cerebral blood flow autoregulation is critical to preventing secondary brain injury. Little is known about the effects of prolonged hypothermia or rewarming on autoregulation after cardiac arrest. We hypothesized that rewarming would shift the lower limit of autoregulation (LLA), that this shift would be detected by indices derived from near-infrared spectroscopy (NIRS), and that rewarming would impair autoregulation during hypertension. Anesthetized neonatal swine underwent sham surgery or hypoxic-asphyxic cardiac arrest, followed by 2 h of normothermia and 20 h of hypothermia, with or without rewarming. Piglets were further divided into cohorts for cortical laser-Doppler flow (LDF) measurements during induced hypotension or hypertension. We also tested whether indices derived from NIRS could identify the LDF-derived LLA. The LLA did not differ significantly among groups with sham surgery and hypothermia (29 ± 8 mmHg), sham surgery and rewarming (34 ± 7 mmHg), arrest and hypothermia (29 ± 10 mmHg), and arrest and rewarming (38 ± 11 mmHg). The LLA was not affected by arrest (P = 0.60), temperature (P = 0.08), or interaction between arrest and temperature (P = 0.73). The NIRS-derived indices detected the LLA accurately, with the area under the receiver-operator characteristic curves of 0.81-0.96 among groups. In groups subjected to arrest and hypothermia, with or without rewarming, the slope of LDF relative to cerebral perfusion pressure during hypertension was not significantly different from zero (P > 0.10). In conclusion, rewarming did not shift the LLA during hypotension or affect autoregulation during hypertension after asphyxic cardiac arrest. The NIRS-derived autoregulation indices identified the LLA accurately.
Collapse
Affiliation(s)
- Abby C Larson
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | | | | | | | | | | | | | | |
Collapse
|
133
|
Ono M, Joshi B, Brady K, Easley RB, Kibler K, Conte J, Shah A, Russell SD, Hogue CW. Cerebral blood flow autoregulation is preserved after continuous-flow left ventricular assist device implantation. J Cardiothorac Vasc Anesth 2013; 26:1022-8. [PMID: 23122299 DOI: 10.1053/j.jvca.2012.07.014] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2012] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To compare cerebral blood flow (CBF) autoregulation in patients undergoing continuous-flow left ventricular assist device (LVAD) implantation with that in patients undergoing coronary artery bypass grafting (CABG). DESIGN Prospective, observational, controlled study. SETTING Academic medical center. PARTICIPANTS Fifteen patients undergoing LVAD insertion and 10 patients undergoing CABG. MEASUREMENTS AND MAIN RESULTS Cerebral autoregulation was monitored with transcranial Doppler and near-infrared spectroscopy. A continuous Pearson correlation coefficient was calculated between mean arterial pressure (MAP) and CBF velocity and between MAP and near-infrared spectroscopic data, rendering the variables mean velocity index (Mx) and cerebral oximetry index (COx), respectively. Mx and COx approach 0 when autoregulation is intact (no correlation between CBF and MAP), but approach 1 when autoregulation is impaired. Mx was lower during and immediately after cardiopulmonary bypass in the LVAD group than in the CABG group, indicating better-preserved autoregulation. Based on COx monitoring, autoregulation tended to be better preserved in the LVAD group than in the CABG group immediately after surgery (p = 0.0906). On postoperative day 1, COx was lower in the LVAD group than in the CABG group, indicating preserved CBF autoregulation (p = 0.0410). Based on COx monitoring, 3 patients (30%) in the CABG group had abnormal autoregulation (COx ≥0.3) on the first postoperative day but no patient in the LVAD group had this abnormality (p = 0.037). CONCLUSIONS These data suggest that CBF autoregulation is preserved during and immediately after surgery in patients undergoing LVAD insertion.
Collapse
Affiliation(s)
- Masahiro Ono
- Department of Surgery, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | | | | | | | | | | |
Collapse
|
134
|
Le Roux P. Physiological monitoring of the severe traumatic brain injury patient in the intensive care unit. Curr Neurol Neurosci Rep 2013; 13:331. [PMID: 23328942 DOI: 10.1007/s11910-012-0331-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Despite encouraging animal research, pharmacological agents and neuroprotectants have disappointed in the clinical environment. Current TBI management therefore is directed towards identification, prevention, and treatment of secondary cerebral insults that are known to exacerbate outcome after injury. This strategy is based on a variety of monitoring techniques that include the neurological examination, imaging, laboratory analysis, and physiological monitoring of the brain and other organ systems used to guide therapeutic interventions. Recent clinical series suggest that TBI management informed by multimodality monitoring is associated with improved patient outcome, in part because care is provided in a patient-specific manner. In this review we discuss physiological monitoring of the brain after TBI and the emerging field of neurocritical care bioinformatics.
Collapse
Affiliation(s)
- Peter Le Roux
- Department of Neurosurgery, University of Pennsylvania, 235 South 8th Street, Philadelphia, PA 19106, USA.
| |
Collapse
|
135
|
Lee JK, Williams M, Jennings JM, Jamrogowicz JL, Larson AC, Jordan LC, Heitmiller ES, Hogue CW, Ahn ES. Cerebrovascular autoregulation in pediatric moyamoya disease. Paediatr Anaesth 2013; 23:547-56. [PMID: 23506446 PMCID: PMC3648623 DOI: 10.1111/pan.12140] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 01/29/2013] [Indexed: 12/17/2022]
Abstract
BACKGROUND Moyamoya syndrome carries a high risk of cerebral ischemia, and impaired cerebrovascular autoregulation may play a critical role. Autoregulation indices derived from near-infrared spectroscopy (NIRS) may clarify hemodynamic goals that conform to the limits of autoregulation. OBJECTIVES The aims of this pilot study were to determine whether the NIRS-derived indices could identify blood pressure ranges that optimize autoregulation and whether autoregulatory function differs between anatomic sides in patients with unilateral vasculopathy. METHODS Pediatric patients undergoing indirect surgical revascularization for moyamoya were enrolled sequentially. NIRS-derived autoregulation indices, the cerebral oximetry index (COx) and the hemoglobin volume index (HVx), were calculated intraoperatively and postoperatively to measure autoregulatory function. The 5-mmHg ranges of optimal mean arterial blood pressure (MAPOPT ) with best autoregulation and the lower limit of autoregulation (LLA) were identified. RESULTS Of seven enrolled patients (aged 2-16 years), six had intraoperative and postoperative autoregulation monitoring and one had only intraoperative monitoring. Intraoperative MAPOPT was identified in six (86%) of seven patients with median values of 60-80 mmHg. Intraoperative LLA was identified in three (43%) patients with median values of 55-65 mmHg. Postoperative MAPOPT was identified in six (100%) of six patients with median values of 70-90 mmHg. Patients with unilateral disease had higher intraoperative HVx (P = 0.012) on side vasculopathy. CONCLUSIONS NIRS-derived indices may identify hemodynamic goals that optimize autoregulation in pediatric moyamoya.
Collapse
Affiliation(s)
- Jennifer K. Lee
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Monica Williams
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Jacky M. Jennings
- The Bloomberg School of Public Health, Baltimore, MD, and The Dept. of Pediatrics, The Johns Hopkins University School of Medicine, USA
| | - Jessica L. Jamrogowicz
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Abby C. Larson
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lori C. Jordan
- Dept. of Neurology, Vanderbilt University, Nashville, TN, USA
| | - Eugenie S. Heitmiller
- Dept. of Anesthesiology and Critical Care Medicine, Division of Pediatric Anesthesia, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Charles W. Hogue
- Dept. of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Edward S. Ahn
- Dept. of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| |
Collapse
|
136
|
Rhee CJ, Kibler KK, Brady KM, Everett AD, Graham EM, Andropoulos DB, Easley RB. Detection of neurologic injury using vascular reactivity monitoring and glial fibrillary acidic protein. Pediatrics 2013; 131:e950-4. [PMID: 23420921 DOI: 10.1542/peds.2012-1702] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Abstract
New noninvasive methods for monitoring cerebrovascular pressure reactivity coupled with a blood-based assay for brain-specific injury in preterm infants could allow early diagnosis of brain injury and set the stage for improved timing and effectiveness of interventions. Using an adaptation of near-infrared spectroscopy, we report a case of a very low birth weight infant undergoing hemoglobin volume index monitoring as a measure of cerebrovascular pressure reactivity. During the monitoring period, this infant demonstrated significant disturbances in cerebrovascular pressure reactivity that coincided with elevation of serum glial fibrillary acidic protein and new findings of brain injury on head ultrasound. This case report demonstrates the potential of emerging noninvasive monitoring methods to assist in both detection and therapeutic management to improve neurologic outcomes of the very low birth weight neonate.
Collapse
Affiliation(s)
- Christopher J Rhee
- Department of Pediatrics, Section of Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, TX 77030, USA.
| | | | | | | | | | | | | |
Collapse
|
137
|
Ono M, Zheng Y, Joshi B, Sigl JC, Hogue CW. Validation of a stand-alone near-infrared spectroscopy system for monitoring cerebral autoregulation during cardiac surgery. Anesth Analg 2012; 116:198-204. [PMID: 23223100 DOI: 10.1213/ane.0b013e318271fb10] [Citation(s) in RCA: 52] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND Individualizing arterial blood pressure (ABP) targets during cardiopulmonary bypass (CPB) based on cerebral blood flow (CBF) autoregulation monitoring may provide a more effective means for preventing cerebral hypoperfusion than the current standard of care. Autoregulation can be monitored in real time with transcranial Doppler (TCD). We have previously demonstrated that near-infrared spectroscopy (NIRS)-derived regional cerebral oxygen saturation (rS(c)O(2)) provides a clinically suitable surrogate of CBF for autoregulation monitoring. The purpose of this study was to determine the accuracy of a stand-alone "plug-and-play" investigational system for autoregulation monitoring that uses a commercially available NIRS monitor with TCD methods. METHODS TCD monitoring of middle cerebral artery CBF velocity and NIRS monitoring were performed in 70 patients during CPB. Indices of autoregulation were computed by both a personal computer-based system and an investigational prototype NIRS-based monitor. A moving linear correlation coefficient between slow waves of ABP and CBF velocity (mean velocity index [Mx]) and between ABP and rS(c)O(2) (cerebral oximetry index [COx]) were calculated. When CBF is autoregulated, there is no correlation between CBF and ABP; when CBF is dysregulated, Mx and COx approach 1 (i.e., CBF and ABP are correlated). Linear regression and bias analysis were performed between time-averaged values of Mx and COx derived from the personal computer-based system and from COx measured with the prototype monitor. Values for Mx and COx were categorized in 5 mm Hg bins of ABP for each patient. The lower limit of CBF autoregulation was defined as the ABP where Mx incrementally increased to ≥0.4. RESULTS There was correlation and good agreement between COx derived from the prototype monitor and Mx (r = 0.510; 95% confidence interval, 0.414-0.595; P < 0.001; bias, -0.07 ± 0.19). The correlation and bias between the personal computer-based COx and the COx from the prototype NIRS monitor were r = 0.957 (95% confidence interval, 0.945-0.966; P < 0.001 and 0.06 ± 0.06, respectively). The average ABP at the lower limit of autoregulation was 63 ± 11 mm Hg (95% prediction interval, 52-74 mm Hg). Although the mean ABP at the COx-determined lower limit of autoregulation determined with the prototype monitor was statistically different from that determined by Mx (59 ± 9 mm Hg; 95% prediction interval, 50-68 mm Hg; P = 0.026), the difference was not likely clinically meaningful. CONCLUSIONS Monitoring CBF autoregulation with an investigational stand-alone NIRS monitor is correlated and in good agreement with TCD-based methods. The availability of such a device would allow widespread autoregulation monitoring as a means of individualizing ABP targets during CPB.
Collapse
Affiliation(s)
- Masahiro Ono
- Division of Cardiac Surgery, Department of Surgery, The Johns Hopkins University School of Medicine, Baltimore, MD 21287, USA
| | | | | | | | | |
Collapse
|
138
|
Brady KM, Easley RB, Kibler K, Kaczka DW, Andropoulos D, Fraser CD, Smielewski P, Czosnyka M, Adams GJ, Rhee CJ, Rusin CG. Positive end-expiratory pressure oscillation facilitates brain vascular reactivity monitoring. J Appl Physiol (1985) 2012; 113:1362-8. [DOI: 10.1152/japplphysiol.00853.2012] [Citation(s) in RCA: 29] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
The pressure reactivity index (PRx) identifies optimal cerebral perfusion pressure after traumatic brain injury. We describe a method to improve PRx precision by induced variations in arterial blood pressure (ABP) using positive end-expiratory pressure (PEEP) modulation ( iPRx). Neonatal swine ( n = 10) were ventilated with static PEEP and then with PEEP oscillated between 5 and 10 cmH2O at a frequency of 1/min. PRx was recorded as a moving correlation coefficient between ABP and intracranial pressure (ICP) from spontaneous ABP activity (0.05-0.003 Hz) during static PEEP. iPRx was similarly recorded with PEEP oscillation-induced ABP waves. The lower limit of autoregulation (LLA) was delineated with continuous cortical laser Doppler flux monitoring. PEEP oscillation increased autoregulation-monitoring precision. The ratios of median absolute deviations to range of possible values for the PRx and iPRx were 9.5% (8.3–13.7%) and 6.2% (4.2–8.7%), respectively ( P = 0.006; median, interquartile range). The phase-angle difference between ABP and ICP above LLA was 161° (150°–166°) and below LLA, −31° (−42° to 12°, P < 0.0001). iPRx above LLA was −0.42 (−0.67 to −0.29) and below LLA, 0.32 (0.22–0.43, P = 0.0004). A positive iPRx was 97% specific and 91% sensitive for perfusion pressure below LLA. PEEP oscillation caused stable, low-frequency ABP oscillations that reduced noise in the PRx. Safe translation of these findings to clinical settings is expected to yield more accurate and rapid delineation of individualized optimal perfusion-pressure goals for patients.
Collapse
Affiliation(s)
- Ken M. Brady
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
- Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - R. Blaine Easley
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
- Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Kathleen Kibler
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Dean Andropoulos
- Anesthesiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
- Pediatrics, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | | | - Peter Smielewski
- Neurosurgical Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Marek Czosnyka
- Neurosurgical Unit, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| | - Gerald J. Adams
- Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Christopher J. Rhee
- Neonatology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| | - Craig G. Rusin
- Cardiology, Texas Children's Hospital, Baylor College of Medicine, Houston, Texas
| |
Collapse
|
139
|
Diedler J, Sorrentino E, Kasprowicz M, Smielewski P, Budohoski K, Czosnyka M. Critical Thresholds for Cerebrovascular Reactivity: Facts, No Fiction! Neurocrit Care 2012. [DOI: 10.1007/s12028-012-9724-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
|
140
|
Highton D, Panovska-Griffiths J, Ghosh A, Tachtsidis I, Banaji M, Elwell C, Smith M. Modelling cerebrovascular reactivity: a novel near-infrared biomarker of cerebral autoregulation? ADVANCES IN EXPERIMENTAL MEDICINE AND BIOLOGY 2012; 765:87-93. [PMID: 22879019 PMCID: PMC4038008 DOI: 10.1007/978-1-4614-4989-8_13] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
Understanding changes in cerebral oxygenation, haemodynamics and metabolism holds the key to individualised, optimised therapy after acute brain injury. Near-infrared spectroscopy (NIRS) offers the potential for non-invasive, continuous bedside measurement of surrogates for these processes. Interest has grown in applying this technique to interpret cerebrovascular pressure reactivity (CVPR), a surrogate of the brain's ability to autoregulate blood flow. We describe a physiological model-based approach to NIRS interpretation which predicts autoregulatory efficiency from a model parameter k_aut. Data from three critically brain-injured patients exhibiting a change in CVPR were investigated. An optimal value for k_aut was determined to minimise the difference between measured and simulated outputs. Optimal values for k_aut appropriately tracked changes in CVPR under most circumstances. Further development of this technique could be used to track CVPR providing targets for individualised management of patients with altered vascular reactivity, minimising secondary neurological insults.
Collapse
Affiliation(s)
- David Highton
- grid.83440.3b0000000121901201Neurocritical Care, University College Hospitals, Queen Square, London, UK ,grid.436283.80000 0004 0612 2631National Hospital for Neurology and Neurosurgery, Flat 40 Salisbury Mansions, St Anns Road, London, N153TP UK
| | - Jasmina Panovska-Griffiths
- grid.83440.3b0000000121901201Medical Physics and Bioengineering, University College London, Malet Place, London, UK
| | - Arnab Ghosh
- grid.83440.3b0000000121901201Neurocritical Care, University College Hospitals, Queen Square, London, UK ,grid.83440.3b0000000121901201Institute of Neurology, University College London, Queen Square, London, UK
| | - Ilias Tachtsidis
- grid.83440.3b0000000121901201Medical Physics and Bioengineering, University College London, Malet Place, London, UK
| | - Murad Banaji
- grid.4701.20000 0001 0728 6636Department of Mathematics, University of Portsmouth, Portsmouth, UK
| | - Clare Elwell
- grid.83440.3b0000000121901201Medical Physics and Bioengineering, University College London, Malet Place, London, UK
| | - Martin Smith
- grid.83440.3b0000000121901201Neurocritical Care, University College Hospitals, Queen Square, London, UK ,grid.83440.3b0000000121901201Medical Physics and Bioengineering, University College London, Malet Place, London, UK
| |
Collapse
|
141
|
Rhee CJ, Kibler KK, Easley RB, Andropoulos DB, Czosnyka M, Smielewski P, Brady KM. Renovascular reactivity measured by near-infrared spectroscopy. J Appl Physiol (1985) 2012; 113:307-14. [DOI: 10.1152/japplphysiol.00024.2012] [Citation(s) in RCA: 56] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
Hypotension and shock are risk factors for death, renal insufficiency, and stroke in preterm neonates. Goal-directed neonatal hemodynamic management lacks end-organ monitoring strategies to assess the adequacy of perfusion. Our aim is to develop a clinically viable, continuous metric of renovascular reactivity to gauge renal perfusion during shock. We present the renovascular reactivity index (RVx), which quantifies passivity of renal blood volume to spontaneous changes in arterial blood pressure. We tested the ability of the RVx to detect reductions in renal blood flow. Hemorrhagic shock was induced in 10 piglets. The RVx was monitored as a correlation between slow waves of arterial blood pressure and relative total hemoglobin (rTHb) obtained with reflectance near-infrared spectroscopy (NIRS) over the kidney. The RVx was compared with laser-Doppler measurements of red blood cell flux, and renal laser-Doppler measurements were compared with cerebral laser-Doppler measurements. Renal blood flow decreased to 75%, 50%, and 25% of baseline at perfusion pressures of 60, 45, and 40 mmHg, respectively, whereas in the brain these decrements occurred at pressures of 30, 25, and 15 mmHg, respectively. The RVx compared favorably to the renal laser-Doppler data. Areas under the receiver operator characteristic curves using renal blood flow thresholds of 50% and 25% of baseline were 0.85 (95% CI, 0.83–0.87) and 0.90 (95% CI, 0.88–0.92). Renovascular autoregulation can be monitored and is impaired in advance of cerebrovascular autoregulation during hemorrhagic shock.
Collapse
Affiliation(s)
- Christopher J. Rhee
- Department of Pediatrics, Section of Neonatology, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Kathleen K. Kibler
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - R. Blaine Easley
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Dean B. Andropoulos
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Department of Academic Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ken M. Brady
- Departments of Anesthesiology, Critical Care Medicine, and Pediatrics, Texas Children's Hospital/Baylor College of Medicine, Houston, Texas
| |
Collapse
|
142
|
Abstract
This article presents an overview of intracranial monitoring techniques during the perioperative and intensive care management of neurologic patients. Various regional and global brain monitors are available; some modalities are well established whereas others are new to the clinical arena and their indications are still being evaluated. Indications for monitoring are reviewed, modalities critically evaluated, and future directions identified.
Collapse
Affiliation(s)
- Matthew A Kirkman
- The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK
| | | |
Collapse
|
143
|
Rosenberg JB, Shiloh AL, Savel RH, Eisen LA. Non-invasive methods of estimating intracranial pressure. Neurocrit Care 2012; 15:599-608. [PMID: 21519957 DOI: 10.1007/s12028-011-9545-4] [Citation(s) in RCA: 66] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Non-invasive measurement of intracranial pressure can be invaluable in the management of critically ill patients. We performed a comprehensive review of the literature to evaluate the different methods of measuring intracranial pressure. Several methods have been employed to estimate intracranial pressure, including computed tomography, magnetic resonance imaging, transcranial Doppler sonography, near-infrared spectroscopy, and visual-evoked potentials. In addition, multiple techniques of measuring the optic nerve and the optic nerve sheath diameter have been studied. Ultrasound measurements of the optic nerve sheath diameter and Doppler flow are especially promising and may be useful in selected settings.
Collapse
Affiliation(s)
- Jamie B Rosenberg
- Department of Ophthalmology and Visual Sciences, Montefiore Medical Center, Albert Einstein College of Medicine, Bronx, NY, USA.
| | | | | | | |
Collapse
|
144
|
Lee JK, Yang ZJ, Wang B, Larson AC, Jamrogowicz JL, Kulikowicz E, Kibler KK, Mytar JO, Carter EL, Burman HT, Brady KM, Smielewski P, Czosnyka M, Koehler RC, Shaffner DH. Noninvasive autoregulation monitoring in a swine model of pediatric cardiac arrest. Anesth Analg 2012; 114:825-36. [PMID: 22314692 DOI: 10.1213/ane.0b013e31824762d5] [Citation(s) in RCA: 44] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
BACKGROUND Cerebrovascular autoregulation after resuscitation has not been well studied in an experimental model of pediatric cardiac arrest. Furthermore, developing noninvasive methods of monitoring autoregulation using near-infrared spectroscopy (NIRS) would be clinically useful in guiding neuroprotective hemodynamic management after pediatric cardiac arrest. We tested the hypotheses that the lower limit of autoregulation (LLA) would shift to a higher arterial blood pressure between 1 and 2 days of recovery after cardiac arrest and that the LLA would be detected by NIRS-derived indices of autoregulation in a swine model of pediatric cardiac arrest. We also tested the hypothesis that autoregulation with hypertension would be impaired after cardiac arrest. METHODS Data on LLA were obtained from neonatal piglets that had undergone hypoxic-asphyxic cardiac arrest and recovery for 1 day (n = 8) or 2 days (n = 8), or that had undergone sham surgery with 2 days of recovery (n = 8). Autoregulation with hypertension was examined in a separate cohort of piglets that underwent hypoxic-asphyxic cardiac arrest (n = 5) or sham surgery (n = 5) with 2 days of recovery. After the recovery period, piglets were reanesthetized, and autoregulation was monitored by standard laser-Doppler flowmetry and autoregulation indices derived from NIRS (the cerebral oximetry [COx] and hemoglobin volume [HVx] indices). The LLA was determined by decreasing blood pressure through inflation of a balloon catheter in the inferior vena cava. Autoregulation during hypertension was evaluated by inflation of an aortic balloon catheter. RESULTS The LLAs were similar between sham-operated piglets and piglets that recovered for 1 or 2 days after arrest. The NIRS-derived indices accurately detected the LLA determined by laser-Doppler flowmetry. The area under the curve of the receiver operator characteristic curve for cerebral oximetry index was 0.91 at 1 day and 0.92 at 2 days after arrest. The area under the curve for hemoglobin volume index was 0.92 and 0.89 at the respective time points. During induced hypertension, the static rate of autoregulation, defined as the percentage change in cerebrovascular resistance divided by the percentage change in cerebral perfusion pressure, was not different between postarrest and sham-operated piglets. At 2 days recovery from arrest, piglets exhibited neurobehavioral deficits and histologic neuronal injury. CONCLUSIONS In a swine model of pediatric hypoxic-asphyxic cardiac arrest with confirmed brain damage, the LLA did not differ 1 and 2 days after resuscitation. The NIRS-derived indices accurately detected the LLA in comparison with laser-Doppler flow measurements at those time points. Autoregulation remained functional during hypertension.
Collapse
Affiliation(s)
- Jennifer K Lee
- Department of Pediatric Anesthesiology and Critical Care Medicine, Johns Hopkins University, Blalock 904, 600 N. Wolfe Street, Baltimore, MD 21287, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
145
|
Budohoski KP, Zweifel C, Kasprowicz M, Sorrentino E, Diedler J, Brady KM, Smielewski P, Menon DK, Pickard JD, Kirkpatrick PJ, Czosnyka M. What comes first? The dynamics of cerebral oxygenation and blood flow in response to changes in arterial pressure and intracranial pressure after head injury. Br J Anaesth 2012; 108:89-99. [PMID: 22037222 PMCID: PMC3236021 DOI: 10.1093/bja/aer324] [Citation(s) in RCA: 53] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 08/01/2011] [Indexed: 11/14/2022] Open
Abstract
BACKGROUND Brain tissue partial oxygen pressure (Pbt(O(2))) and near-infrared spectroscopy (NIRS) are novel methods to evaluate cerebral oxygenation. We studied the response patterns of Pbt(O(2)), NIRS, and cerebral blood flow velocity (CBFV) to changes in arterial pressure (AP) and intracranial pressure (ICP). METHODS Digital recordings of multimodal brain monitoring from 42 head-injured patients were retrospectively analysed. Response latencies and patterns of Pbt(O(2)), NIRS-derived parameters [tissue oxygenation index (TOI) and total haemoglobin index (THI)], and CBFV reactions to fluctuations of AP and ICP were studied. RESULTS One hundred and twenty-one events were identified. In reaction to alterations of AP, ICP reacted first [4.3 s; inter-quartile range (IQR) -4.9 to 22.0 s, followed by NIRS-derived parameters and CBFV (10.9 s; IQR: -5.9 to 39.6 s, 12.1 s; IQR: -3.0 to 49.1 s, 14.7 s; IQR: -8.8 to 52.3 s for THI, CBFV, and TOI, respectively), with Pbt(O(2)) reacting last (39.6 s; IQR: 16.4 to 66.0 s). The differences in reaction time between NIRS parameters and Pbt(O(2)) were significant (P<0.001). Similarly when reactions to ICP changes were analysed, NIRS parameters preceded Pbt(O(2)) (7.1 s; IQR: -8.8 to 195.0 s, 18.1 s; IQR: -20.6 to 80.7 s, 22.9 s; IQR: 11.0 to 53.0 s for THI, TOI, and Pbt(O(2)), respectively). Two main patterns of responses to AP changes were identified. With preserved cerebrovascular reactivity, TOI and Pbt(O(2)) followed the direction of AP. With impaired cerebrovascular reactivity, TOI and Pbt(O(2)) decreased while AP and ICP increased. In 77% of events, the direction of TOI changes was concordant with Pbt(O(2)). CONCLUSIONS NIRS and transcranial Doppler signals reacted first to AP and ICP changes. The reaction of Pbt(O(2)) is delayed. The results imply that the analysed modalities monitor different stages of cerebral oxygenation.
Collapse
Affiliation(s)
- K P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Addenbrooke' s Hospital, Hills Road, Cambridge CB2 0QQ, UK.
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
146
|
Joshi B, Ono M, Brown C, Brady K, Easley RB, Yenokyan G, Gottesman RF, Hogue CW. Predicting the limits of cerebral autoregulation during cardiopulmonary bypass. Anesth Analg 2011; 114:503-10. [PMID: 22104067 DOI: 10.1213/ane.0b013e31823d292a] [Citation(s) in RCA: 195] [Impact Index Per Article: 15.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
BACKGROUND Mean arterial blood pressure (MAP) targets are empirically chosen during cardiopulmonary bypass (CPB). We have previously shown that near-infrared spectroscopy (NIRS) can be used clinically for monitoring cerebral blood flow autoregulation. The hypothesis of this study was that real-time autoregulation monitoring using NIRS-based methods is more accurate for delineating the MAP at the lower limit of autoregulation (LLA) during CPB than empiric determinations based on age, preoperative history, and preoperative blood pressure. METHODS Two hundred thirty-two patients undergoing coronary artery bypass graft and/or valve surgery with CPB underwent transcranial Doppler monitoring of the middle cerebral arteries and NIRS monitoring. A continuous, moving Pearson correlation coefficient was calculated between MAP and cerebral blood flow velocity and between MAP and NIRS data to generate mean velocity index and cerebral oximeter index. When autoregulated, there is no correlation between cerebral blood flow and MAP (i.e., mean velocity and cerebral oximetry indices approach 0); when MAP is below the LLA, mean velocity and cerebral oximetry indices approach 1. The LLA was defined as the MAP at which mean velocity index increased with declining MAP to ≥ 0.4. Linear regression was performed to assess the relation between preoperative systolic blood pressure, MAP, MAP in 10% decrements from baseline, and average cerebral oximetry index with MAP at the LLA. RESULTS The MAP at the LLA was 66 mm Hg (95% prediction interval, 43 to 90 mm Hg) for the 225 patients in which this limit was observed. There was no relationship between preoperative MAP and the LLA (P = 0.829) after adjusting for age, gender, prior stroke, diabetes, and hypertension, but a cerebral oximetry index value of >0.5 was associated with the LLA (P = 0.022). The LLA could be identified with cerebral oximetry index in 219 (94.4%) patients. The mean difference in the LLA for mean velocity index versus cerebral oximetry index was -0.2 ± 10.2 mm Hg (95% CI, -1.5 to 1.2 mm Hg). Preoperative systolic blood pressure was associated with a higher LLA (P = 0.046) but only for those with systolic blood pressure ≤ 160 mm Hg. CONCLUSIONS There is a wide range of MAP at the LLA in patients during CPB, making estimation of this target difficult. Real-time monitoring of autoregulation with cerebral oximetry index may provide a more rational means for individualizing MAP during CPB.
Collapse
Affiliation(s)
- Brijen Joshi
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Johns Hopkins Hospital, 600 N. Wolfe St., Tower 711, Baltimore, MD 21287, USA
| | | | | | | | | | | | | | | |
Collapse
|
147
|
Cerebral blood flow and cerebrovascular autoregulation in a swine model of pediatric cardiac arrest and hypothermia. Crit Care Med 2011; 39:2337-45. [PMID: 21705904 DOI: 10.1097/ccm.0b013e318223b910] [Citation(s) in RCA: 81] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVE Knowledge remains limited regarding cerebral blood flow autoregulation after cardiac arrest and during postresuscitation hypothermia. We determined the relationship of cerebral blood flow to cerebral perfusion pressure in a swine model of pediatric hypoxic-asphyxic cardiac arrest during normothermia and hypothermia and tested novel measures of autoregulation derived from near-infrared spectroscopy. DESIGN Prospective, balanced animal study. SETTING Basic physiology laboratory at an academic institution. SUBJECTS Eighty-four neonatal swine. INTERVENTIONS Piglets underwent hypoxic-asphyxic cardiac arrest or sham surgery and recovered for 2 hrs with normothermia followed by 4 hrs of either moderate hypothermia or normothermia. In half of the groups, blood pressure was slowly decreased through inflation of a balloon catheter in the inferior vena cava to identify the lower limit of cerebral autoregulation at 6 hrs postresuscitation. In the remaining groups, blood pressure was gradually increased by inflation of a balloon catheter in the aorta to determine the autoregulatory response to hypertension. Measures of autoregulation obtained from standard laser-Doppler flowmetry and indices derived from near-infrared spectroscopy were compared. MEASUREMENTS AND MAIN RESULTS Laser-Doppler flux was lower in postarrest animals compared to sham-operated controls during the 2-hr normothermic period after resuscitation. During the subsequent 4-hr recovery, hypothermia decreased laser-Doppler flux in both the sham surgery and postarrest groups. Autoregulation was intact during hypertension in all groups. With arterial hypotension, postarrest, hypothermic piglets had a significant decrease in the perfusion pressure lower limit of autoregulation compared to postarrest, normothermic piglets. The near-infrared spectroscopy-derived measures of autoregulation accurately detected loss of autoregulation during hypotension. CONCLUSIONS In a pediatric model of cardiac arrest and resuscitation, delayed induction of hypothermia decreased cerebral perfusion and decreased the lower limit of autoregulation. Metrics derived from noninvasive near-infrared spectroscopy accurately identified the lower limit of autoregulation during normothermia and hypothermia in piglets resuscitated from arrest.
Collapse
|
148
|
Relationship between cerebrovascular dysautoregulation and arterial blood pressure in the premature infant. J Perinatol 2011; 31:722-9. [PMID: 21372795 DOI: 10.1038/jp.2011.17] [Citation(s) in RCA: 64] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
OBJECTIVE To evaluate cerebrovascular autoregulation as a function of arterial blood pressure (ABP) in the critically ill, premature infant. STUDY DESIGN A prospective observational pilot study was conducted in two tertiary care Neonatal Intensive-Care Units. Premature infants (n=23, ≤30 weeks estimated gestational age with invasive ABP monitoring) were enrolled and received routine care while undergoing continuous autoregulation monitoring, using the cerebral oximetry index (COx). The COx is a moving, linear correlation coefficient between cortical reflectance oximetry and ABP. COx values were stratified as a function of ABP for individual subject recordings and for the cohort. RESULT The mean duration of autoregulation monitoring was 3.2 days (median: 2.97, range: 0.61-3.99). A total of 10 of 23 (43%) developed intraventricular hemorrhage and 1 of 23 (4%) developed periventricular leukomalacia by head ultrasound. No association was found between neurologic injury and percentage of the monitoring periods with autoregulation impairment (defined as COx>0.5). Lower ABP was associated with dysautoregulation (higher COx values, P<0.01). The percentage of time with impaired autoregulation was greater with lower ABP (P=0.013, Spearman r=0.51). CONCLUSION All infants studied had periods with intact and periods with impaired cerebrovascular autoregulation, measured with the COx. Low ABP was associated with impaired autoregulation.
Collapse
|
149
|
Brain oxygen tension monitoring following penetrating ballistic-like brain injury in rats. J Neurosci Methods 2011; 203:115-21. [PMID: 21983109 DOI: 10.1016/j.jneumeth.2011.09.025] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2011] [Revised: 09/22/2011] [Accepted: 09/23/2011] [Indexed: 11/22/2022]
Abstract
While brain oxygen tension (PbtO(2)) monitoring is an important parameter for evaluating injury severity and therapeutic efficiency in severe traumatic brain injury (TBI) patients, many factors affect the monitoring. The goal of this study was to identify the effects of FiO(2) (fraction of inspired oxygen) on PbtO(2) in uninjured anesthetized rats and measure the changes in PbtO(2) following penetrating ballistic-like brain injury (PBBI). Continuous PbtO(2) monitoring in uninjured anesthetized rats showed that PbtO(2) response was positively correlated with FiO(2) (0.21-0.35) but PbtO(2) remained stable when FiO(2) was maintained at ∼0.26. Importantly, although increasing FiO(2) from 0.21 to 0.35 improved P(a)O(2), it concomitantly reduced pH levels and elevated P(a)CO(2) values out of the normal range. However, when the FiO(2) was maintained between 0.26 and 0.30, the pH and P(a)O(2) levels remained within the normal or clinically acceptable range. In PBBI rats, PbtO(2) was significantly reduced by ∼40% (16.9 ± 1.2 mm Hg) in the peri-lesional region immediately following unilateral, frontal 10% PBBI compared to sham rats (28.6 ± 1.7 mm Hg; mean ± SEM, p<0.05) and the PBBI-induced reductions in PbtO(2) were sustained for at least 150 min post-PBBI. Collectively, these results demonstrate that FiO(2) affects PbtO(2) and that PBBI produces acute and sustained hypoxia in the peri-lesional region of the brain injury. This study provides important information for the management of PbtO(2) monitoring in this brain injury model and may offer insight for therapeutic strategies targeted to improve the hypoxia/ischemia state in the penetrating-type brain injury.
Collapse
|
150
|
Diedler J, Zweifel C, Budohoski KP, Kasprowicz M, Sorrentino E, Haubrich C, Brady KM, Czosnyka M, Pickard JD, Smielewski P. The limitations of near-infrared spectroscopy to assess cerebrovascular reactivity: the role of slow frequency oscillations. Anesth Analg 2011; 113:849-57. [PMID: 21821514 DOI: 10.1213/ane.0b013e3182285dc0] [Citation(s) in RCA: 43] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
BACKGROUND A total hemoglobin reactivity index (THx) derived from near-infrared spectroscopy (NIRS) has recently been introduced to assess cerebrovascular reactivity noninvasively. Analogously to the pressure reactivity index (PRx), THx is calculated as correlation coefficient with arterial blood pressure (ABP). However, the reliability of THx in the injured brain is uncertain. Although slow oscillations have been described in NIRS signals, their significance for assessment of autoregulation remains unclear. In the current study, we investigated the role of slow oscillations of total hemoglobin for NIRS-based cerebrovascular reactivity monitoring. METHODS This study was based on a retrospective analysis of data that were consecutively recorded for a different project published previously. Thirty-seven patients with traumatic brain injury and admitted to Addenbrooke's Neurosciences Critical Care Unit between June 2008 and June 2009 were included. After artifact removal, we performed spectral analysis of the tissue hemoglobin index (THI, a measure of oxy- and deoxygenated hemoglobin) and intracranial pressure (ICP) signal. PRx and THx were calculated as moving correlations between ICP and ABP, and THI and ABP, respectively. The agreement between PRx and THx as a function of normalized power of slow oscillations (0.015-0.055 Hz) contained in the input signals was assessed performing between-subject and within-subject correlation analyses. Furthermore, the correlation between the THx values derived from the right and left sides was analyzed. RESULTS The agreement between PRx and THx depended on the power of slow oscillations in the input signals. Between-subject comparisons revealed a significant correlation between THx and PRx (r = 0.80, 95% confidence interval 0.53-0.92, P < 0.01) for patients with normalized slow wave activity >0.4 in the THI signal, compared with r = 0.07 (95% confidence interval -0.40 to 0.51, P = 0.79) in the remaining files. Furthermore, within-subject comparisons suggested that THx may be used as a substitute for PRx only when there is an at least moderate agreement (r = 0.36) between the THx values derived from the right and left sides. CONCLUSIONS Our results suggest that the NIRS-based cerebrovascular reactivity index THx can be used as a noninvasive substitute for PRx, but only during phases with sufficient slow wave power in the input signal. Furthermore, a good agreement between the THx measures on both sides seems to be a prerequisite for comparison of a global (PRx) versus the more local (THx) index. Nevertheless, noninvasive assessment of cerebrovascular reactivity may be desirable in patients without ICP monitoring and help to guide ABP management in these patients.
Collapse
Affiliation(s)
- Jennifer Diedler
- Academic Neurosurgical Unit, University of Cambridge Clinical School, Cambridge, United Kingdom.
| | | | | | | | | | | | | | | | | | | |
Collapse
|