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Murkin JM, Kamar M, Silman Z, Balberg M, Adams SJ. Intraoperative Cerebral Autoregulation Assessment Using Ultrasound-Tagged Near-Infrared-Based Cerebral Blood Flow in Comparison to Transcranial Doppler Cerebral Flow Velocity: A Pilot Study. J Cardiothorac Vasc Anesth 2015; 29:1187-93. [DOI: 10.1053/j.jvca.2015.05.201] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/20/2015] [Indexed: 11/11/2022]
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Abstract
OBJECTIVE Traumatic brain injury is a significant cause of morbidity and mortality in children. Cerebral autoregulation disturbance after traumatic brain injury is associated with worse outcome. Pressure reactivity is a fundamental component of cerebral autoregulation that can be estimated using the pressure-reactivity index, a correlation between slow arterial blood pressure, and intracranial pressure fluctuations. Pressure-reactivity index has shown prognostic value in adult traumatic brain injury, with one study confirming this in children. Pressure-reactivity index can identify a cerebral perfusion pressure range within which pressure reactivity is optimal. An increasing difference between optimal cerebral perfusion pressure and cerebral perfusion pressure is associated with worse outcome in adult traumatic brain injury; however, this has not been investigated in children. Our objective was to study pressure-reactivity index and optimal cerebral perfusion pressure in pediatric traumatic brain injury, including associations with outcome, age, and cerebral perfusion pressure. DESIGN Prospective observational study. SETTING ICU, Royal Children's Hospital, Melbourne, Australia. PATIENTS Patients with traumatic brain injury who are 6 months to 16 years old, are admitted to the ICU, and require arterial blood pressure and intracranial pressure monitoring. INTERVENTIONS None. MEASUREMENTS AND MAIN RESULTS Arterial blood pressure, intracranial pressure, and end-tidal CO2 were recorded electronically until ICU discharge or monitoring cessation. Pressure-reactivity index and optimal cerebral perfusion pressure were computed according to previously published methods. Clinical data were collected from electronic medical records. Outcome was assessed 6 months post discharge using the modified Glasgow Outcome Score. Thirty-six patients were monitored, with 30 available for follow-up. Pressure-reactivity index correlated with modified Glasgow Outcome Score (Spearman ρ = 0.42; p = 0.023) and was higher in patients with unfavorable outcome (0.23 vs -0.09; p = 0.0009). A plot of pressure-reactivity index averaged within 5 mm Hg cerebral perfusion pressure bins showed a U-shape, reaffirming the concept of cerebral perfusion pressure optimization in children. Optimal cerebral perfusion pressure increased with age (ρ = 0.40; p = 0.02). Both the duration and magnitude of negative deviations in the difference between cerebral perfusion pressure and optimal cerebral perfusion pressure were associated with unfavorable outcome. CONCLUSIONS In pediatric patients with traumatic brain injury, pressure-reactivity index has prognostic value and can identify cerebral perfusion pressure targets that may differ from treatment protocols. Our results suggest but do not confirm that cerebral perfusion pressure targeting using pressure-reactivity index as a guide may positively impact on outcome. This question should be addressed by a prospective clinical study.
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103
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Logsdon AF, Lucke-Wold BP, Turner RC, Huber JD, Rosen CL, Simpkins JW. Role of Microvascular Disruption in Brain Damage from Traumatic Brain Injury. Compr Physiol 2015; 5:1147-60. [PMID: 26140712 PMCID: PMC4573402 DOI: 10.1002/cphy.c140057] [Citation(s) in RCA: 101] [Impact Index Per Article: 11.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
Traumatic brain injury (TBI) is acquired from an external force, which can inflict devastating effects to the brain vasculature and neighboring neuronal cells. Disruption of vasculature is a primary effect that can lead to a host of secondary injury cascades. The primary effects of TBI are rapidly occurring while secondary effects can be activated at later time points and may be more amenable to targeting. Primary effects of TBI include diffuse axonal shearing, changes in blood-brain barrier (BBB) permeability, and brain contusions. These mechanical events, especially changes to the BBB, can induce calcium perturbations within brain cells producing secondary effects, which include cellular stress, inflammation, and apoptosis. These secondary effects can be potentially targeted to preserve the tissue surviving the initial impact of TBI. In the past, TBI research had focused on neurons without any regard for glial cells and the cerebrovasculature. Now a greater emphasis is being placed on the vasculature and the neurovascular unit following TBI. A paradigm shift in the importance of the vascular response to injury has opened new avenues of drug-treatment strategies for TBI. However, a connection between the vascular response to TBI and the development of chronic disease has yet to be elucidated. Long-term cognitive deficits are common amongst those sustaining severe or multiple mild TBIs. Understanding the mechanisms of cellular responses following TBI is important to prevent the development of neuropsychiatric symptoms. With appropriate intervention following TBI, the vascular network can perhaps be maintained and the cellular repair process possibly improved to aid in the recovery of cellular homeostasis.
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Affiliation(s)
- Aric F Logsdon
- Department of Pharmaceutical Sciences, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Department of Neurosurgery, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Center for Neuroscience, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
| | - Brandon P Lucke-Wold
- Department of Neurosurgery, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Center for Neuroscience, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
| | - Ryan C Turner
- Department of Neurosurgery, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Center for Neuroscience, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
| | - Jason D Huber
- Department of Pharmaceutical Sciences, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Department of Neurosurgery, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Center for Neuroscience, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
| | - Charles L Rosen
- Department of Neurosurgery, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Center for Neuroscience, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
| | - James W Simpkins
- Department of Physiology and Pharmacology, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
- Center for Neuroscience, West Virginia University, Health Sciences Center, Morgantown, West Virginia, USA
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104
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Reis C, Wang Y, Akyol O, Ho WM, Ii RA, Stier G, Martin R, Zhang JH. What's New in Traumatic Brain Injury: Update on Tracking, Monitoring and Treatment. Int J Mol Sci 2015; 16:11903-65. [PMID: 26016501 PMCID: PMC4490422 DOI: 10.3390/ijms160611903] [Citation(s) in RCA: 48] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/26/2015] [Revised: 05/04/2015] [Accepted: 05/06/2015] [Indexed: 12/11/2022] Open
Abstract
Traumatic brain injury (TBI), defined as an alteration in brain functions caused by an external force, is responsible for high morbidity and mortality around the world. It is important to identify and treat TBI victims as early as possible. Tracking and monitoring TBI with neuroimaging technologies, including functional magnetic resonance imaging (fMRI), diffusion tensor imaging (DTI), positron emission tomography (PET), and high definition fiber tracking (HDFT) show increasing sensitivity and specificity. Classical electrophysiological monitoring, together with newly established brain-on-chip, cerebral microdialysis techniques, both benefit TBI. First generation molecular biomarkers, based on genomic and proteomic changes following TBI, have proven effective and economical. It is conceivable that TBI-specific biomarkers will be developed with the combination of systems biology and bioinformation strategies. Advances in treatment of TBI include stem cell-based and nanotechnology-based therapy, physical and pharmaceutical interventions and also new use in TBI for approved drugs which all present favorable promise in preventing and reversing TBI.
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Affiliation(s)
- Cesar Reis
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Yuechun Wang
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Physiology, School of Medicine, University of Jinan, Guangzhou 250012, China.
| | - Onat Akyol
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
| | - Wing Mann Ho
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, University Hospital Innsbruck, Tyrol 6020, Austria.
| | - Richard Applegate Ii
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Gary Stier
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - Robert Martin
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
| | - John H Zhang
- Department of Anesthesiology, Loma Linda University Medical Center, Loma Linda, CA 92354, USA.
- Department of Physiology and Pharmacology, Loma Linda University School of Medicine, 11041 Campus Street, Risley Hall, Room 219, Loma Linda, CA 92354, USA.
- Department of Neurosurgery, Loma Linda University School of Medicine, Loma Linda, CA 92354, USA.
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105
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Güiza F, Depreitere B, Piper I, Citerio G, Chambers I, Jones PA, Lo TYM, Enblad P, Nillson P, Feyen B, Jorens P, Maas A, Schuhmann MU, Donald R, Moss L, Van den Berghe G, Meyfroidt G. Visualizing the pressure and time burden of intracranial hypertension in adult and paediatric traumatic brain injury. Intensive Care Med 2015; 41:1067-76. [DOI: 10.1007/s00134-015-3806-1] [Citation(s) in RCA: 156] [Impact Index Per Article: 17.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2015] [Accepted: 04/05/2015] [Indexed: 11/27/2022]
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106
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Lang EW, Kasprowicz M, Smielewski P, Santos E, Pickard J, Czosnyka M. Short pressure reactivity index versus long pressure reactivity index in the management of traumatic brain injury. J Neurosurg 2015; 122:588-94. [DOI: 10.3171/2014.10.jns14602] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT
The pressure reactivity index (PRx) correlates with outcome after traumatic brain injury (TBI) and is used to calculate optimal cerebral perfusion pressure (CPPopt). The PRx is a correlation coefficient between slow, spontaneous changes (0.003–0.05 Hz) in intracranial pressure (ICP) and arterial blood pressure (ABP). A novel index—the so-called long PRx (L-PRx)—that considers ABP and ICP changes (0.0008–0.008 Hz) was proposed.
METHODS
The authors compared PRx and L-PRx for 6-month outcome prediction and CPPopt calculation in 307 patients with TBI. The PRx- and L-PRx–based CPPopt were determined and the predictive power and discriminant abilities were compared.
RESULTS
The PRx and L-PRx correlation was good (R = 0.7, p < 0.00001; Spearman test). The PRx, age, CPP, and Glasgow Coma Scale score but not L-PRx were significant fatal outcome predictors (death and persistent vegetative state). There was a significant difference between the areas under the receiver operating characteristic curves calculated for PRx and L-PRx (0.61 ± 0.04 vs 0.51 ± 0.04; z-statistic = −3.26, p = 0.011), which indicates a better ability by PRx than L-PRx to predict fatal outcome. The CPPopt was higher for L-PRx than for PRx, without a statistical difference (median CPPopt for L-PRx: 76.9 mm Hg, interquartile range [IQR] ± 10.1 mm Hg; median CPPopt for PRx: 74.7 mm Hg, IQR ± 8.2 mm Hg). Death was associated with CPP below CPPopt for PRx (χ2 = 30.6, p < 0.00001), and severe disability was associated with CPP above CPPopt for PRx (χ2 = 7.8, p = 0.005). These relationships were not statistically significant for CPPopt for L-PRx.
CONCLUSIONS
The PRx is superior to the L-PRx for TBI outcome prediction. Individual CPPopt for L-PRx and PRx are not statistically different. Deviations between CPP and CPPopt for PRx are relevant for outcome prediction; those between CPP and CPPopt for L-PRx are not. The PRx uses the entire B-wave spectrum for index calculation, whereas the L-PRX covers only one-third of it. This may explain the performance discrepancy.
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Affiliation(s)
| | - Magdalena Kasprowicz
- 2Institute of Biomedical Engineering and Instrumentation, Wroclaw University of Technology, Wroclaw, Poland; and
| | - Peter Smielewski
- 3Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | - Edgar Santos
- 4Department of Neurosurgery, University of Heidelberg, Germany
| | - John Pickard
- 3Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, United Kingdom
| | - Marek Czosnyka
- 3Department of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, United Kingdom
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107
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Sánchez-Porras R, Santos E, Silos H, Sakowitz OW. Letter to the Editor. Minute-by-minute monitoring of autoregulation. J Neurosurg 2014; 121:1289-90. [DOI: 10.3171/2014.5.jns141056] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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108
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KOIZUMI H, SUEHIRO E, FUJIYAMA Y, SUGIMOTO K, INOUE T, SUZUKI M. Update on intensive neuromonitoring for patients with traumatic brain injury: a review of the literature and the current situation. Neurol Med Chir (Tokyo) 2014; 54:870-7. [PMID: 25367587 PMCID: PMC4533348 DOI: 10.2176/nmc.ra.2014-0168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/28/2014] [Indexed: 11/20/2022] Open
Abstract
Intracranial pressure (ICP) measurements are fundamental in the present protocols for intensive care of patients during the acute stage of severe traumatic brain injury. However, the latest report of a large scale randomized clinical trial indicated no association of ICP monitoring with any significant improvement in neurological outcome in severely head injured patients. Aggressive treatment of patients with therapeutic hypothermia during the acute stage of traumatic brain injury also failed to show any significant beneficial effects on clinical outcome. This lack of significant results in clinical trials has limited the therapeutic strategies available for treatment of severe traumatic brain injury. However, combined application of different types of neuromonitoring, including ICP measurement, may have potential benefits for understanding the pathophysiology of damaged brains. The combination of monitoring techniques is expected to increase the precision of the data and aid in prevention of secondary brain damage, as well as assist in determining appropriate time periods for therapeutic interventions. In this study, we have characterized the techniques used to monitor patients during the acute severe traumatic brain injury stage, in order to establish the beneficial effects on outcome observed in clinical studies conducted in the past and to follow up any valuable clues that point to additional strategies for aggressive management of these patients.
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Affiliation(s)
- Hiroyasu KOIZUMI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Eiichi SUEHIRO
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Yuichi FUJIYAMA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Kazutaka SUGIMOTO
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Takao INOUE
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Michiyasu SUZUKI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
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109
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Hawthorne C, Piper I. Monitoring of intracranial pressure in patients with traumatic brain injury. Front Neurol 2014; 5:121. [PMID: 25076934 PMCID: PMC4100218 DOI: 10.3389/fneur.2014.00121] [Citation(s) in RCA: 74] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/17/2014] [Accepted: 06/25/2014] [Indexed: 02/01/2023] Open
Abstract
Since Monro published his observations on the nature of the contents of the intracranial space in 1783, there has been investigation of the unique relationship between the contents of the skull and the intracranial pressure (ICP). This is particularly true following traumatic brain injury (TBI), where it is clear that elevated ICP due to the underlying pathological processes is associated with a poorer clinical outcome. Consequently, there is considerable interest in monitoring and manipulating ICP in patients with TBI. The two techniques most commonly used in clinical practice to monitor ICP are via an intraventricular or intraparenchymal catheter with a microtransducer system. Both of these techniques are invasive and are thus associated with complications such as hemorrhage and infection. For this reason, significant research effort has been directed toward development of a non-invasive method to measure ICP. The principle aims of ICP monitoring in TBI are to allow early detection of secondary hemorrhage and to guide therapies that limit intracranial hypertension (ICH) and optimize cerebral perfusion. However, information from the ICP value and the ICP waveform can also be used to assess the intracranial volume-pressure relationship, estimate cerebrovascular pressure reactivity, and attempt to forecast future episodes of ICH.
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Affiliation(s)
- Christopher Hawthorne
- Clinical Lecturer, Academic Unit of Anaesthesia, Pain and Critical Care Medicine, University of Glasgow, Glasgow, UK
| | - Ian Piper
- Clinical Physics, Southern General Hospital, Greater Glasgow Health Board, Glasgow, UK
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