1
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Lele AV, Moreton EO, Sundararajan J, Blacker SN. Perioperative care of patients with recent stroke undergoing nonemergent, nonneurological, noncardiac, nonvascular surgery: a systematic review and meta-analysis. Curr Opin Anaesthesiol 2024; 37:460-469. [PMID: 39011660 DOI: 10.1097/aco.0000000000001403] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/17/2024]
Abstract
PURPOSE OF REVIEW To systematically review and perform a meta-analysis of published literature regarding postoperative stroke and mortality in patients with a history of stroke and to provide a framework for preoperative, intraoperative, and postoperative care in an elective setting. RECENT FINDINGS Patients with nonneurological, noncardiac, and nonvascular surgery within three months after stroke have a 153-fold risk, those within 6 months have a 50-fold risk, and those within 12 months have a 20-fold risk of postoperative stroke. There is a 12-fold risk of in-hospital mortality within three months and a three-to-four-fold risk of mortality for more than 12 months after stroke. The risk of stroke and mortality continues to persist years after stroke. Recurrent stroke is common in patients in whom anticoagulation/antiplatelet therapy is discontinued. Stroke and time elapsed after stroke should be included in the preoperative assessment questionnaire, and a stroke-specific risk assessment should be performed before surgical planning is pursued. SUMMARY In patients with a history of a recent stroke, anesthesiology, surgery, and neurology experts should create a shared mental model in which the patient/surrogate decision-maker is informed about the risks and benefits of the proposed surgical procedure; secondary-stroke-prevention medications are reviewed; plans are made for interruptions and resumption; and intraoperative care is individualized to reduce the likelihood of postoperative stroke or death.
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Affiliation(s)
- Abhijit V Lele
- Department of Anesthesiology and Pain Medicine, University of Washington, Harborview Medical Center, Seattle, Washington
| | | | | | - Samuel Neal Blacker
- Department of Anesthesiology, University of North Carolina, Chapel Hill, North Carolina, USA
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2
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Carlson AP, Mayer AR, Cole C, van der Horn HJ, Marquez J, Stevenson TC, Shuttleworth CW. Cerebral autoregulation, spreading depolarization, and implications for targeted therapy in brain injury and ischemia. Rev Neurosci 2024; 35:651-678. [PMID: 38581271 PMCID: PMC11297425 DOI: 10.1515/revneuro-2024-0028] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2024] [Accepted: 03/25/2024] [Indexed: 04/08/2024]
Abstract
Cerebral autoregulation is an intrinsic myogenic response of cerebral vasculature that allows for preservation of stable cerebral blood flow levels in response to changing systemic blood pressure. It is effective across a broad range of blood pressure levels through precapillary vasoconstriction and dilation. Autoregulation is difficult to directly measure and methods to indirectly ascertain cerebral autoregulation status inherently require certain assumptions. Patients with impaired cerebral autoregulation may be at risk of brain ischemia. One of the central mechanisms of ischemia in patients with metabolically compromised states is likely the triggering of spreading depolarization (SD) events and ultimately, terminal (or anoxic) depolarization. Cerebral autoregulation and SD are therefore linked when considering the risk of ischemia. In this scoping review, we will discuss the range of methods to measure cerebral autoregulation, their theoretical strengths and weaknesses, and the available clinical evidence to support their utility. We will then discuss the emerging link between impaired cerebral autoregulation and the occurrence of SD events. Such an approach offers the opportunity to better understand an individual patient's physiology and provide targeted treatments.
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Affiliation(s)
- Andrew P. Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Andrew R. Mayer
- Mind Research Network, 1101 Yale, Blvd, NE, Albuquerque, NM, 87106, USA
| | - Chad Cole
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | | | - Joshua Marquez
- University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
| | - Taylor C. Stevenson
- Department of Neurosurgery, University of New Mexico School of Medicine, MSC10 5615, 1 UNM, Albuquerque, NM, 87131, USA
| | - C. William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, 915 Camino de Salud NE, Albuquerque, NM, 87106, USA
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3
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Chalifoux N, Ko T, Slovis J, Spelde A, Kilbaugh T, Mavroudis CD. Cerebral Autoregulation: A Target for Improving Neurological Outcomes in Extracorporeal Life Support. Neurocrit Care 2024:10.1007/s12028-024-02002-5. [PMID: 38811513 DOI: 10.1007/s12028-024-02002-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 04/18/2024] [Indexed: 05/31/2024]
Abstract
Despite improvements in survival after illnesses requiring extracorporeal life support, cerebral injury continues to hinder successful outcomes. Cerebral autoregulation (CA) is an innate protective mechanism that maintains constant cerebral blood flow in the face of varying systemic blood pressure. However, it is impaired in certain disease states and, potentially, following initiation of extracorporeal circulatory support. In this review, we first discuss patient-related factors pertaining to venovenous and venoarterial extracorporeal membrane oxygenation (ECMO) and their potential role in CA impairment. Next, we examine factors intrinsic to ECMO that may affect CA, such as cannulation, changes in pulsatility, the inflammatory and adaptive immune response, intracranial hemorrhage, and ischemic stroke, in addition to ECMO management factors, such as oxygenation, ventilation, flow rates, and blood pressure management. We highlight potential mechanisms that lead to disruption of CA in both pediatric and adult populations, the challenges of measuring CA in these patients, and potential associations with neurological outcome. Altogether, we discuss individualized CA monitoring as a potential target for improving neurological outcomes in extracorporeal life support.
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Affiliation(s)
- Nolan Chalifoux
- Department of Clinical Sciences and Advanced Medicine, School of Veterinary Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
- Institute for Translational Medicine and Therapeutics, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA.
| | - Tiffany Ko
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Julia Slovis
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Audrey Spelde
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Todd Kilbaugh
- Department of Anesthesiology and Critical Care Medicine, University of Pennsylvania, Philadelphia, PA, 19104, USA
| | - Constantine D Mavroudis
- Division of Cardiothoracic Surgery, Children's Hospital of Philadelphia, Philadelphia, PA, 19104, USA
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4
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Kalisvaart ACJ, Abrahart AH, Coney AT, Gu S, Colbourne F. Intracranial Pressure Dysfunction Following Severe Intracerebral Hemorrhage in Middle-Aged Rats. Transl Stroke Res 2023; 14:970-986. [PMID: 36367666 PMCID: PMC10640482 DOI: 10.1007/s12975-022-01102-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2022] [Revised: 10/14/2022] [Accepted: 11/02/2022] [Indexed: 11/13/2022]
Abstract
Rising intracranial pressure (ICP) aggravates secondary injury and heightens risk of death following intracerebral hemorrhage (ICH). Long-recognized compensatory mechanisms that lower ICP include reduced cerebrospinal fluid and venous blood volumes. Recently, we identified another compensatory mechanism in severe stroke, a decrease in cerebral parenchymal volume via widespread reductions in cell volume and extracellular space (tissue compliance). Here, we examined how age affects tissue compliance and ICP dynamics after severe ICH in rats (collagenase model). A planned comparison to historical young animal data revealed that aged SHAMs (no stroke) had significant cerebral atrophy (9% reduction, p ≤ 0.05), ventricular enlargement (9% increase, p ≤ 0.05), and smaller CA1 neuron volumes (21%, p ≤ 0.05). After ICH in aged animals, contralateral striatal neuron density and CA1 astrocyte density significantly increased (12% for neurons, 7% for astrocytes, p ≤ 0.05 vs. aged SHAMs). Unlike young animals, other regions in aged animals did not display significantly reduced cell soma volume despite a few trends. Nonetheless, overall contralateral hemisphere volume was 10% smaller in aged ICH animals compared to aged SHAMs (p ≤ 0.05). This age-dependent pattern of tissue compliance is not due to absent ICH-associated mass effect (83.2 mm3 avg. bleed volume) as aged ICH animals had significantly elevated mean and peak ICP (p ≤ 0.01), occurrence of ICP spiking events, as well as bilateral evidence of edema (e.g., 3% in injured brain, p ≤ 0.05 vs. aged SHAMs). Therefore, intracranial compliance reserve changes with age; after ICH, these and other age-related changes may cause greater fluctuation from baseline, increasing the chance of adverse outcomes like mortality.
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Affiliation(s)
| | - Ashley H Abrahart
- Department of Psychology, University of Alberta, Edmonton, AB, Canada
| | - Alyvia T Coney
- Department of Psychology, University of Alberta, Edmonton, AB, Canada
| | - Sherry Gu
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Frederick Colbourne
- Department of Psychology, University of Alberta, Edmonton, AB, Canada.
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
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5
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Gan L, Yin X, Huang J, Jia B. Transcranial Doppler analysis based on computer and artificial intelligence for acute cerebrovascular disease. MATHEMATICAL BIOSCIENCES AND ENGINEERING : MBE 2023; 20:1695-1715. [PMID: 36899504 DOI: 10.3934/mbe.2023077] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/18/2023]
Abstract
Cerebrovascular disease refers to damage to brain tissue caused by impaired intracranial blood circulation. It usually presents clinically as an acute nonfatal event and is characterized by high morbidity, disability, and mortality. Transcranial Doppler (TCD) ultrasonography is a non-invasive method for the diagnosis of cerebrovascular disease that uses the Doppler effect to detect the hemodynamic and physiological parameters of the major intracranial basilar arteries. It can provide important hemodynamic information that cannot be measured by other diagnostic imaging techniques for cerebrovascular disease. And the result parameters of TCD ultrasonography such as blood flow velocity and beat index can reflect the type of cerebrovascular disease and serve as a basis to assist physicians in the treatment of cerebrovascular diseases. Artificial intelligence (AI) is a branch of computer science which is used in a wide range of applications in agriculture, communications, medicine, finance, and other fields. In recent years, there are much research devoted to the application of AI to TCD. The review and summary of related technologies is an important work to promote the development of this field, which can provide an intuitive technical summary for future researchers. In this paper, we first review the development, principles, and applications of TCD ultrasonography and other related knowledge, and briefly introduce the development of AI in the field of medicine and emergency medicine. Finally, we summarize in detail the applications and advantages of AI technology in TCD ultrasonography including the establishment of an examination system combining brain computer interface (BCI) and TCD ultrasonography, the classification and noise cancellation of TCD ultrasonography signals using AI algorithms, and the use of intelligent robots to assist physicians in TCD ultrasonography and discuss the prospects for the development of AI in TCD ultrasonography.
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Affiliation(s)
- Lingli Gan
- Department of Neurology, Chongqing General Hospital, Chongqing 401147, China
| | - Xiaoling Yin
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
| | - Jiating Huang
- Department of Infectious Diseases and Public Health, Jockey Club College of Veterinary Medicine and Life Sciences, City University of Hong Kong, Hong Kong, China
| | - Bin Jia
- Department of Neurosurgery, Chongqing General Hospital, Chongqing 401147, China
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6
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The utility of therapeutic hypothermia on cerebral autoregulation. JOURNAL OF INTENSIVE MEDICINE 2022; 3:27-37. [PMID: 36789361 PMCID: PMC9924009 DOI: 10.1016/j.jointm.2022.08.004] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 07/26/2022] [Accepted: 08/10/2022] [Indexed: 11/07/2022]
Abstract
Cerebral autoregulation (CA) dysfunction is a strong predictor of clinical outcome in patients with acute brain injury (ABI). CA dysfunction is a potential pathologic defect that may lead to secondary injury and worse functional outcomes. Early therapeutic hypothermia (TH) in patients with ABI is controversial. Many factors, including patient selection, timing, treatment depth, duration, and rewarming strategy, impact its clinical efficacy. Therefore, optimizing the benefit of TH is an important issue. This paper reviews the state of current research on the impact of TH on CA function, which may provide the basis and direction for CA-oriented target temperature management.
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7
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Schlachetzki F, Nedelmann M, Eyding J, Ritter M, Schminke U, Schulte-Altedorneburg G, Köhrmann M, Harrer JU. Sonografisches Neuromonitoring auf der Stroke Unit und in der
neurologischen Intensivmedizin. KLIN NEUROPHYSIOL 2022. [DOI: 10.1055/a-1810-0728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022]
Abstract
Zusammenfassung
Hintergrund Der Artikel gibt einen Überblick über die
aktuellen diagnostischen Einsatzmöglichkeiten sonographischer Anwendung
in der neurologischen Intensivmedizin.
Methoden Selektive Literaturrecherche mit kritischer Beurteilung ab dem
Jahr 1984 sowie nationaler und internationaler Leitlinien sowie
Expertenmeinung.
Ergebnisse Neben der raschen validen Abklärung akuter
Schlaganfälle bieten verschiedene neurosonografische
Monitoring-verfahren gerade in der Intensivmedizin spezifische Vorteile wie die
beliebig häufige Wiederholbarkeit am Patientenbett selbst und die
Darstellung in Echtzeit. Innovative Entwicklungen machen die Neurosonografie
auch wissenschaftlich zu einem interessanten Gebiet.
Schlussfolgerung Die neurosonografische Diagnostik nimmt seit Jahren einen
wichtigen Stellenwert in der neurologischen Intensivmedizin ein. Weitere
Anstrengungen sind notwendig, um die Verbreitung der Methode zu fördern
und durch wissenschaftliche Evidenz zu stärken.
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Affiliation(s)
- Felix Schlachetzki
- Klinik und Poliklinik für Neurologie der Universität
Regensburg, Zentrum für Vaskuläre Neurologie und
Intensivmedizin, medbo Bezirksklinikum Regensburg, Regensburg
- Klinik und Poliklinik für Neurologie,
Universitätsklinikum Regensburg, Regensburg
| | - Max Nedelmann
- Klinik für Neurologie, Regio Kliniken Pinneberg,
Pinneberg
| | - Jens Eyding
- Abteilung für Neurologie, Gemeinschaftskrankenhaus Herdecke und
Medizinische Fakultät der Ruhr-Universität Bochum,
Bochum
| | | | - Ulf Schminke
- Klinik für Neurologie, Universitätsmedizin Greifswald,
Greifswald
| | | | | | - Judith U. Harrer
- Neurologische Praxis in der Villa Pfahler, St. Ingbert
- Klinik für Neurologie, Universitätsklinikum der RWTH
Aachen, Aachen
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8
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Moncion K, Allison EY, Al-Khazraji BK, MacDonald MJ, Roig M, Tang A. What are the effects of acute exercise and exercise training on cerebrovascular hemodynamics following stroke? A systematic review and meta-analysis. J Appl Physiol (1985) 2022; 132:1379-1393. [PMID: 35482325 DOI: 10.1152/japplphysiol.00872.2021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/22/2022] Open
Abstract
INTRODUCTION Limited data exist regarding the effects of acute exercise and exercise training on cerebrovascular hemodynamic variables post-stroke. PURPOSE This systematic review and meta-analysis 1) examined the effects of acute exercise and exercise training on cerebrovascular hemodynamic variables reported in the stroke exercise literature; and 2) synthesized the peak middle cerebral artery blood velocity (MCAv) achieved during an acute bout of moderate-intensity exercise in individuals post-stroke. METHODS Six databases (MEDLINE, EMBASE, Web of Science, CINAHL, PsycINFO, AMED) were searched from inception to December 1st 2021, for studies that examined the effect of acute exercise or exercise training on cerebrovascular hemodynamics in adults post-stroke. Two reviewers conducted title and abstract screening, full-text evaluation, data extraction, and quality appraisal. Random effects models were used in meta-analysis. RESULTS Nine studies, including 4 acute exercise (n=61) and 5 exercise training studies (n=193), were included. Meta-analyses were not statistically feasible for several cerebrovascular hemodynamic variables. Descriptive analysis reveals that exercise training may increase cerebral blood flow and cerebrovascular reactivity to carbon dioxide among individuals post-stroke. Meta-analysis of three acute exercise studies revealed no significant changes in MCAv during acute moderate intensity exercise (n=48 participants, mean difference = 5.2 cm/s, 95% CI [-0.6, 11.0], P=0.08) compared to resting MCAv values. CONCLUSION This review suggests that individuals post-stroke may have attenuated cerebrovascular hemodynamics as measured by the MCAv during acute moderate-intensity exercise. Higher quality research utilizing agreed upon hemodynamic variables are needed to synthesize the effects of exercise training on cerebrovascular hemodynamics post-stroke.
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Affiliation(s)
- Kevin Moncion
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
| | - Elric Y Allison
- Department of Kinesiology, Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Baraa K Al-Khazraji
- Department of Kinesiology, Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Maureen J MacDonald
- Department of Kinesiology, Faculty of Science, McMaster University, Hamilton, Ontario, Canada
| | - Marc Roig
- School of Physical and Occupational Therapy, Faculty of Medicine, McGill University, Montreal, Québec, Canada
| | - Ada Tang
- School of Rehabilitation Sciences, Faculty of Health Sciences, McMaster University, Hamilton, Ontario, Canada
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9
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Minhas JS, Moullaali TJ, Rinkel GJE, Anderson CS. Blood Pressure Management After Intracerebral and Subarachnoid Hemorrhage: The Knowns and Known Unknowns. Stroke 2022; 53:1065-1073. [PMID: 35255708 DOI: 10.1161/strokeaha.121.036139] [Citation(s) in RCA: 25] [Impact Index Per Article: 12.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Blood pressure (BP) elevations often complicate the management of intracerebral hemorrhage and aneurysmal subarachnoid hemorrhage, the most serious forms of acute stroke. Despite consensus on potential benefits of BP lowering in the acute phase of intracerebral hemorrhage, controversies persist over the timing, mechanisms, and approaches to treatment. BP control is even more complex for subarachnoid hemorrhage, where there are rationales for both BP lowering and elevation in reducing the risks of rebleeding and delayed cerebral ischemia, respectively. Efforts to disentangle the evidence has involved detailed exploration of individual patient data from clinical trials through meta-analysis to determine strength and direction of BP change in relation to key outcomes in intracerebral hemorrhage, and which likely also apply to subarachnoid hemorrhage. A wealth of hemodynamic data provides insights into pathophysiological interrelationships of BP and cerebral blood flow. This focused update provides an overview of current evidence, knowledge gaps, and emerging concepts on systemic hemodynamics, cerebral autoregulation and perfusion, to facilitate clinical practice recommendations and future research.
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Affiliation(s)
- Jatinder S Minhas
- Department of Cardiovascular Sciences (J.S.M.), University of Leicester, United Kingdom
- NIHR Leicester Biomedical Research Centre (J.S.M.), University of Leicester, United Kingdom
| | - Tom J Moullaali
- Centre for Clinical Brain Sciences, University of Edinburgh, United Kingdom (T.J.M.)
- Department of Clinical Neurosciences, NHS Lothian, United Kingdom (T.J.M.)
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (T.J.M., C.S.A.)
| | - Gabriel J E Rinkel
- Department of Neurology & Neurosurgery, University Medical Centre Utrecht, University of Utrecht, the Netherlands (G.J.E.R.)
- Department of Neurosurgery, University Hospital Mannheim, University of Heidelberg, Germany (G.J.E.R.)
| | - Craig S Anderson
- The George Institute for Global Health, University of New South Wales, Sydney, Australia (T.J.M., C.S.A.)
- The George Institute China at Peking University Health Sciences Centre, Beijing, P.R. China (C.S.A.)
- Neurology Department, Royal Prince Alfred Hospital, Sydney Health Partners, Sydney, Australia (C.S.A.)
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10
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Robinson TG, Minhas JS, Miller J. Review of major trials of acute blood pressure management in stroke. J Cereb Blood Flow Metab 2022; 42:404-410. [PMID: 33761781 PMCID: PMC8851668 DOI: 10.1177/0271678x211004310] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Revised: 02/01/2021] [Accepted: 02/17/2021] [Indexed: 02/02/2023]
Abstract
Over the last two decades, there have been a number of major landmark clinical trials, classified as "major" as they sought to address clear clinical practice driven questions, in a pragmatic yet robust trial design, using a large powered sample size (n > 1000), in order to help improve patient outcome through informing guidelines. A commonality across all stroke sub-types included in these trials is the tendency to acute hypertensive crises within the acute stroke period. This phenomenon is associated with greater stroke complications and worsened overall prognosis. Multiple trials have attempted to address the issue of acute blood pressure management during the acute stroke period, with consideration for timing, magnitude of lowering, agent and relationship to other interventions. This review will consider the major clinical trials performed in ischaemic and haemorrhagic stroke that test the hypothesis that acute BP reduction improves clinical outcomes.
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Affiliation(s)
- Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK
- National Institute for Health Research Leicester Biomedical
Research Centre, The Glenfield Hospital, Leicester, UK
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester,
Leicester, UK
- National Institute for Health Research Leicester Biomedical
Research Centre, The Glenfield Hospital, Leicester, UK
| | - Joseph Miller
- Department of Emergency Medicine, Henry Ford Hospital and Wayne
State University, Detroit, MI, USA
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11
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ZENG X, XU X, KONG J, RONG C, SHE J, GUO W, SHI L, ZHAO D. Effect of Puerarin on EBI after SAH. FOOD SCIENCE AND TECHNOLOGY 2022. [DOI: 10.1590/fst.45021] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 04/03/2023]
Affiliation(s)
- Xiangwu ZENG
- The Second People's Hospital of Zhangye City, China
| | - Xiuzhen XU
- The Second People's Hospital of Zhangye City, China
| | | | - Congxue RONG
- The Second People's Hospital of Zhangye City, China
| | - Jianhu SHE
- The Second People's Hospital of Zhangye City, China
| | - Wanliang GUO
- The Second People's Hospital of Zhangye City, China
| | - Lijuan SHI
- The Second People's Hospital of Zhangye City, China
| | - Dianfan ZHAO
- The Second People's Hospital of Zhangye City, China
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12
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Claassen JAHR, Thijssen DHJ, Panerai RB, Faraci FM. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation. Physiol Rev 2021; 101:1487-1559. [PMID: 33769101 PMCID: PMC8576366 DOI: 10.1152/physrev.00022.2020] [Citation(s) in RCA: 304] [Impact Index Per Article: 101.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.
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Affiliation(s)
- Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- >National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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13
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Beishon LC, Minhas JS. Cerebral Autoregulation and Neurovascular Coupling in Acute and Chronic Stroke. Front Neurol 2021; 12:720770. [PMID: 34539560 PMCID: PMC8446264 DOI: 10.3389/fneur.2021.720770] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/04/2021] [Accepted: 08/11/2021] [Indexed: 11/13/2022] Open
Affiliation(s)
- Lucy C. Beishon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
| | - Jatinder S. Minhas
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- National Institute for Health Research (NIHR) Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
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14
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Ince J, Mankoo AS, Kadicheeni M, Swienton D, Panerai RB, Robinson TG, Minhas JS. Cerebrovascular tone and resistance measures differ between healthy control and patients with acute intracerebral haemorrhage: exploratory analyses from the BREATHE-ICH study. Physiol Meas 2021; 42. [PMID: 33853052 DOI: 10.1088/1361-6579/abf7da] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Accepted: 04/14/2021] [Indexed: 11/12/2022]
Abstract
Objective.Cerebral autoregulation impairment in acute neurovascular disease is well described. The recent BREATHE-ICH study demonstrated improvements in dynamic cerebral autoregulation, by hypocapnia generated by hyperventilation, in the acute period following intracranial haemorrhage (ICH). This exploratory analysis of the BREATHE-ICH dataset aims to examine the differences in hypocapnic responses between healthy controls and patients with ICH, and determine whether haemodynamic indices differ between baseline and hypocapnic states.Approach.Acute ICH patients were recruited within 48 h of onset and healthy volunteers were recruited from a university setting. Transcranial Doppler measurements of the middle cerebral artery were obtained at baseline and then a hyperventilation intervention was used to induce hypocapnia. Patients with ICH were then followed up at 10-14 D post-event for repeated measurements.Main results.Data from 43 healthy controls and 12 patients with acute ICH met the criteria for statistical analysis. In both normocapnic and hypocapnic conditions, significantly higher critical closing pressure and resistance area product were observed in patients with ICH. Furthermore, critical closing pressure changes were observed to be sustained at 10-14 D follow up. During both the normocapnic and hypocapnic states, reduced autoregulation index was observed bilaterally in patients with ICH, compared to healthy controls.Significance.Whilst this exploratory analysis was limited by a small, non-age matched sample, significant differences between ICH patients and healthy controls were observed in factors associated with cerebrovascular tone and resistance. These differences suggest underlying cerebral autoregulation changes in ICH, which may play a pivotal role in the morbidity and mortality associated with ICH.
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Affiliation(s)
- Jonathan Ince
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Alex S Mankoo
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - Meeriam Kadicheeni
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom
| | - David Swienton
- Department of Radiology, University Hospitals of Leicester NHS Trust, Leicester, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
| | - Jatinder S Minhas
- Department of Cardiovascular Sciences, University of Leicester, United Kingdom.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, United Kingdom
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15
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Kadicheeni M, Robinson TG, Divall P, Parry-Jones AR, Minhas JS. Therapeutic Variation in Lowering Blood Pressure: Effects on Intracranial Pressure in Acute Intracerebral Haemorrhage. High Blood Press Cardiovasc Prev 2021; 28:115-128. [PMID: 33599966 DOI: 10.1007/s40292-021-00435-z] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/27/2020] [Accepted: 02/03/2021] [Indexed: 12/29/2022] Open
Abstract
INTRODUCTION Intracerebral haemorrhage (ICH) is associated with high morbidity and mortality. Blood pressure (BP) control is one of the main management strategies in acute ICH. Limited data currently exist regarding intracranial pressure (ICP) in acute ICH. The relationship between BP lowering and ICP is yet to be fully elucidated. METHODS We conducted a systematic review to investigate the effects of BP lowering on ICP in acute ICH. The study protocol was registered on PROSPERO (CRD42019134470). RESULTS Following PRISMA guidelines, MEDLINE, EMBASE and CENTRAL were searched for studies on ICH with BP and ICP or surrogate measures. 1096 articles were identified after duplicates were removed; 18 studies meeting the inclusion criteria. Dihydropyridine calcium channel blockers (CCBs) were the most common agent used to lower BP, but had a varying effect on ICP. Other BP-lowering agents used also had a varying effect on ICP. DISCUSSION AND CONCLUSION Further work, including large observational or randomized interventional studies, is needed to develop a better understanding of the effect of BP lowering on ICP in acute ICH, which will assist the development of more effective management strategies. TRIAL REGISTRATION The study protocol was registered on PROSPERO (CRD42019134470) on 29/05/2019.
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Affiliation(s)
- Meeriam Kadicheeni
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.
| | - Thompson G Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
| | - Pip Divall
- University Hospitals of Leicester NHS Trust, Leicester, UK
| | - Adrian R Parry-Jones
- Division of Cardiovascular Sciences, School of Medical Sciences, University of Manchester, Manchester Academic Health Science Centre, Oxford Road, Manchester, UK
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, Leicester, UK
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Andalib S, Lattanzi S, Di Napoli M, Petersen A, Biller J, Kulik T, Macri E, Girotra T, Torbey MT, Divani AA. Blood Pressure Variability: A New Predicting Factor for Clinical Outcomes of Intracerebral Hemorrhage. J Stroke Cerebrovasc Dis 2020; 29:105340. [DOI: 10.1016/j.jstrokecerebrovasdis.2020.105340] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/04/2020] [Revised: 09/10/2020] [Accepted: 09/18/2020] [Indexed: 02/06/2023] Open
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Chen J, Liu J, Dong K, Wang Y, Zhao X, Wang Y, Gong X. Impaired Dynamic Cerebral Autoregulation in Cerebral Venous Thrombosis. Front Neurol 2020; 11:570306. [PMID: 33240198 PMCID: PMC7680926 DOI: 10.3389/fneur.2020.570306] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/07/2020] [Accepted: 10/19/2020] [Indexed: 11/29/2022] Open
Abstract
Background: Cerebral autoregulation is crucial in traumatic brain injury, which might be used for determining the optimal intracranial pressure. Cerebral venous thrombosis (CVT) is a cerebral vascular disease with features of high intracranial pressure. However, the autoregulatory mechanism of CVT remains unknown. We aimed to investigate the capacity of cerebral autoregulation in patients with CVT. Methods: This study consecutively enrolled 23 patients with CVT and 16 controls from December 2018 to May 2019. Cerebral autoregulation was assessed by transfer function analysis (rate of recovery/phase/gain) using the spontaneous oscillations of the cerebral blood flow velocity and arterial blood pressure. Results: In total, 76 middle cerebral arteries (MCAs) were investigated, including 44 MCAs in patients with CVT and 32 normal ones. The phase shift estimated in patients with CVT was significantly different from that of the controls (37.37 ± 36.53 vs. 54.00 ± 26.78, p = 0.03). The rate of recovery and gain in patients with CVT were lower than those in controls but without statistical significance. Conclusion: To our knowledge, this is the first time that a study has indicated that patients with CVT were more likely to have impaired cerebral autoregulation. Hence, cautious blood pressure control is required in such patients to prevent hyper- or hypoperfusion.
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Affiliation(s)
- Jie Chen
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Kehui Dong
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yilong Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xingquan Zhao
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yongjun Wang
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Xiping Gong
- Vascular Neurology, Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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18
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Thorpe SG, Thibeault CM, Canac N, Jalaleddini K, Dorn A, Wilk SJ, Devlin T, Scalzo F, Hamilton RB. Toward automated classification of pathological transcranial Doppler waveform morphology via spectral clustering. PLoS One 2020; 15:e0228642. [PMID: 32027714 PMCID: PMC7004309 DOI: 10.1371/journal.pone.0228642] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2019] [Accepted: 01/20/2020] [Indexed: 11/21/2022] Open
Abstract
Cerebral Blood Flow Velocity waveforms acquired via Transcranial Doppler (TCD) can provide evidence for cerebrovascular occlusion and stenosis. Thrombolysis in Brain Ischemia (TIBI) flow grades are widely used for this purpose, but require subjective assessment by expert evaluators to be reliable. In this work we seek to determine whether TCD morphology can be objectively assessed using an unsupervised machine learning approach to waveform categorization. TCD beat waveforms were recorded at multiple depths from the Middle Cerebral Arteries of 106 subjects; 33 with Large Vessel Occlusion (LVO). From each waveform, three morphological features were extracted, quantifying onset of maximal velocity, systolic canopy length, and the number/prominence of peaks/troughs. Spectral clustering identified groups implicit in the resultant three-dimensional feature space, with gap statistic criteria establishing the optimal cluster number. We found that gap statistic disparity was maximized at four clusters, referred to as flow types I, II, III, and IV. Types I and II were primarily composed of control subject waveforms, whereas types III and IV derived mainly from LVO patients. Cluster morphologies for types I and IV aligned clearly with Normal and Blunted TIBI flows, respectively. Types II and III represented commonly observed flow-types not delineated by TIBI, which nonetheless deviate from normal and blunted flows. We conclude that important morphological variability exists beyond that currently quantified by TIBI in populations experiencing or at-risk for acute ischemic stroke, and posit that the observed flow-types provide the foundation for objective methods of real-time automated flow type classification.
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Affiliation(s)
- Samuel G. Thorpe
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
- * E-mail:
| | - Corey M. Thibeault
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Nicolas Canac
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Kian Jalaleddini
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Amber Dorn
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Seth J. Wilk
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
| | - Thomas Devlin
- Department of Neurology, Erlanger Medical Center, Chattanooga, Tennessee, United States of America
| | - Fabien Scalzo
- Department of Neurology, University of California Los Angeles, Los Angeles, California, United States of America
| | - Robert B. Hamilton
- Department of Research, Neural Analytics, Inc., Los Angeles, California, United States of America
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19
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A Novel Nonlinear System Identification for Cerebral Autoregulation in Human: Computer Simulation and Validation. Ann Biomed Eng 2019; 48:1207-1217. [PMID: 31873829 PMCID: PMC8956359 DOI: 10.1007/s10439-019-02442-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/04/2019] [Accepted: 12/14/2019] [Indexed: 10/25/2022]
Abstract
Cerebral autoregulation in healthy humans was studied using a novel methodology adapted from Bendat nonlinear analysis technique. A computer simulation of a high-pass filter in parallel with a cubic nonlinearity followed by a low-pass filter was analyzed. A linear system transfer function analysis showed an incorrect estimate of the gain, cut-off frequency, and phase of the high-pass filter. By contrast, using our nonlinear systems identification, yielded the correct gain, cut-off frequency, and phase of the linear system, and accurately quantified the nonlinear system and following low-pass filter. Adding the nonlinear and linear coherence function indicated a complete description of the system. Cerebral blood flow velocity and arterial pressure were measured in six data sets. Application of the linear and nonlinear systems identification techniques to the data showed a high-pass filter, like the linear transfer function, but the gain was smaller. The phase was similar between the two techniques. The linear coherence was low for frequencies below 0.1 Hz but improved by including a nonlinear term. The linear + nonlinear coherence was approximately 0.9 across the frequency bandwidth, indicating an improved description over the linear system analysis of the cerebral autoregulation system.
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20
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Intharakham K, Beishon L, Panerai RB, Haunton VJ, Robinson TG. Assessment of cerebral autoregulation in stroke: A systematic review and meta-analysis of studies at rest. J Cereb Blood Flow Metab 2019; 39:2105-2116. [PMID: 31433714 PMCID: PMC6827119 DOI: 10.1177/0271678x19871013] [Citation(s) in RCA: 35] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Dynamic cerebral autoregulation (dCA) has been shown to be impaired in cerebrovascular diseases, but there is a lack of consistency across different studies and the different metrics that have been proposed for assessment. We performed a systematic review and meta-analyses involving assessment of dCA in ischemic and hemorrhagic stroke. Thirty-three articles describing assessment of dCA with transfer function analysis (TFA) were included, with meta-analyses performed for derived parameters of gain, phase and autoregulation index (ARI). A total of 1233 patients were pooled from 12 studies on acute ischemic stroke (AIS) and two studies on intracerebral hemorrhage (ICH). In comparison with controls, TFA phase of AIS was significantly reduced (nine studies), in both hemispheres (P < 0.0001). TFA gain provided inconsistent results, with reduced values in relation to controls, for both hemispheres. The ARI (six studies) was reduced compared to controls, in both hemispheres (P < 0.005). In ICH, gain showed higher values compared to controls for the unaffected (P = 0.01), but not for the affected hemisphere. Meta-analyses in AIS have demonstrated that phase and the ARI index can show highly significant differences in comparison with healthy controls, while ICH have been limited by the scarcity of studies and the diversity of units adopted for gain.
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Affiliation(s)
| | - Lucy Beishon
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
| | - Victoria J Haunton
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
| | - Thompson G Robinson
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, British Heart Foundation Cardiovascular Research Centre, Glenfield Hospital, Leicester, UK
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21
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Minhas JS, Panerai RB, Swienton D, Robinson TG. Feasibility of improving cerebral autoregulation in acute intracerebral hemorrhage (BREATHE-ICH) study: Results from an experimental interventional study. Int J Stroke 2019; 15:627-637. [DOI: 10.1177/1747493019873690] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
Background Cerebral autoregulation is impaired in a multitude of neurological conditions. Increasingly, clinical studies are correlating the nature of this impairment with prognostic markers. In acute intracerebral hemorrhage, impairment of cerebral autoregulation has been associated with worsening clinical outcomes including poorer Glasgow Coma Score and larger hematoma volume. Hypocapnia has been shown to improve cerebral autoregulation despite concerns over hypoperfusion and consequent ischemic risks, and it is therefore hypothesized that hypocapnia (via hyperventilation) in acute intracerebral hemorrhage may improve cerebral autoregulation and consequently clinical outcome. Aims To assess the feasibility and acceptability of the first cerebral autoregulation-targeted intervention in acute intracerebral hemorrhage utilizing a simple bed-side hyperventilatory maneuver. Methods Twelve patients with acute intracerebral hemorrhage within 48 h of onset were enrolled. The experimental setup measured cerebral blood flow velocity (transcranial Doppler), blood pressure (Finometer), and end-tidal CO2 (EtCO2, capnography) at baseline, and in response to hypocapnia (−5 mmHg below baseline) achieved via a 90-s hyperventilatory maneuver. Cerebral autoregulation was evaluated with transfer function analysis and autoregulatory index calculations. Results We observed tolerance to the protocol in a cohort of mild (National Institutes of Health Scale 4) supratentorial intracerebral hemorrhage patients with small volume hematomas without intraventricular extension. Importantly, a significant difference was noted between ipsilateral autoregulatory index at baseline 4.8 (1.7) and autoregulatory index during hypocapnic intervention 7.0 (0.8) (p = 0.0004), reflecting improved cerebral autoregulation, though a dose-dependent effect of EtCO2 on autoregulatory index was not observed. Conclusions In this small study, there was no observed effect on 14-day death and disability in recruited participants. This is the first report of improvement in cerebral autoregulation in acute intracerebral hemorrhage using a non-invasive interventional maneuver, through induction of hypocapnia via hyperventilation. ClinicalTrials.gov Identifier: NCT03324321 URL: https://clinicaltrials.gov/ct2/show/NCT03324321
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Affiliation(s)
- Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Ronney B Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
| | - David Swienton
- Department of Radiology, University Hospitals of Leicester, Leicester, UK
| | - Thompson G Robinson
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Research Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
- National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, UK
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22
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Do acute stroke patients develop hypocapnia? A systematic review and meta-analysis. J Neurol Sci 2019; 402:30-39. [DOI: 10.1016/j.jns.2019.04.038] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/12/2019] [Revised: 04/12/2019] [Accepted: 04/29/2019] [Indexed: 12/14/2022]
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Cerebral metabolism is not affected by moderate hyperventilation in patients with traumatic brain injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:45. [PMID: 30760295 PMCID: PMC6375161 DOI: 10.1186/s13054-018-2304-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/29/2018] [Accepted: 12/26/2018] [Indexed: 12/22/2022]
Abstract
Background Hyperventilation-induced hypocapnia (HV) reduces elevated intracranial pressure (ICP), a dangerous and potentially fatal complication of traumatic brain injury (TBI). HV decreases the arteriolar diameter of intracranial vessels, raising the risk of cerebral ischemia. The aim of this study was to characterize the effects of moderate short-term HV in patients with severe TBI by using concomitant monitoring of cerebral metabolism, brain tissue oxygen tension (PbrO2), and cerebral hemodynamics with transcranial color-coded duplex sonography (TCCD). Methods This prospective trial was conducted between May 2014 and May 2017 in the surgical intensive care unit (ICU) at the University Hospital of Zurich. Patients with nonpenetrating TBI older than 18 years of age with a Glasgow Coma Scale (GCS) score < 9 at presentation and with ICP monitoring, PbrO2, and/or microdialysis (MD) probes during ICU admission within 36 h after injury were included in our study. Data collection and TCCD measurements were performed at baseline (A), at the beginning of moderate HV (C), after 50 min of moderate HV (D), and after return to baseline (E). Moderate HV was defined as arterial partial pressure of carbon dioxide 4–4.7 kPa. Repeated measures analysis of variance was used to compare variables at the different time points, followed by post hoc analysis with Bonferroni adjustment as appropriate. Results Eleven patients (64% males, mean age 36 ± 14 years) with an initial median GCS score of 7 (IQR 3–8) were enrolled. During HV, ICP and mean flow velocity (CBFV) in the middle cerebral artery decreased significantly. Glucose, lactate, and pyruvate in the brain extracellular fluid did not change significantly, whereas PbrO2 showed a statistically significant reduction but remained within the normal range. Conclusion Moderate short-term hyperventilation has a potent effect on the cerebral blood flow, as shown by TCCD, with a concomitant ICP reduction. Under the specific conditions of this study, this degree of hyperventilation did not induce pathological alterations of brain metabolites and oxygenation. Trial registration NCT03822026. Registered on 30 January 2019.
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24
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Minhas JS, Kennedy C, Robinson TG, Panerai RB. Different strategies to initiate and maintain hyperventilation: their effect on continuous estimates of dynamic cerebral autoregulation. Physiol Meas 2019; 40:015003. [PMID: 30577035 DOI: 10.1088/1361-6579/aafab6] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
OBJECTIVE Capnography is a key monitoring intervention in several neurologically vulnerable clinical states. Cerebral autoregulation (CA) describes the ability of the cerebrovascular system to maintain a near constant cerebral blood flow throughout fluctuations in systemic arterial blood pressure, with the partial pressure of arterial carbon dioxide known to directly influence CA. Previous work has demonstrated dysautoregulation lasting around 30 s prior to the anticipated augmentation of hyperventilation-associated hypocapnia. In order assess to potential benefit of hypocapnic interventions in an acute stroke setting, minimisation of dysregulation is paramount. APPROACH Hyperventilation strategies to induce and maintain hypocapnia were performed in 61 healthy participants, effects on temporal estimates of dynamic cerebral autoregulation (autoregulation index, ARI) were assessed to validate the most effective strategy for inducing and maintaining hypocapnia. MAIN RESULTS The extent of initial decrease was significantly smaller in the continuous metronome strategy compared to the delayed metronome and voluntary strategies (▵ARI 0.33 ± 1.18, 2.80 ± 3.33 and 3.69 ± 2.79 respectively, p < 0.017). SIGNIFICANCE The use of a continuous metronome to induce hypocapnia rather than the sudden inception of an auditory stimulus appears to reduce the initial decrease in autoregulatory capacity seen in previous studies. Dysautoregulation can be minimised by continuous metronome use during hyperventilation-induced hypocapnia. This advancement in understanding of the behaviour of CA during hypocapnia permits safer delivery of CA targeted interventions, particularly in neurologically vulnerable patient populations.
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Affiliation(s)
- Jatinder S Minhas
- Department of Cardiovascular Sciences, Cerebral Haemodynamics in Ageing and Stroke Medicine (CHIASM) Cardiovascular Sciences Research Group, University of Leicester, Leicester, United Kingdom. Department of Cardiovascular Sciences, University of Leicester, Leicester LE2 7LX, United Kingdom. Author to whom any correspondence should be addressed
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