Monitoring cerebral oxygenation: experimental studies and preliminary clinical results of continuous monitoring of cerebrospinal fluid and brain tissue oxygen tension

Electrochemical Evaluation of a Multi-Site Clinical Depth Recording Electrode for Monitoring Cerebral Tissue Oxygen

The intracranial measurement of local cerebral tissue oxygen levels—PbtO₂—has become a useful tool for the critical care unit to investigate severe trauma and ischemia injury in patients. Our preliminary work in animal models supports the hypothesis that multi-site depth electrode recording of PbtO₂ may give surgeons and critical care providers needed information about brain viability and the capacity for better recovery. Here, we present a surface morphology characterization and an electrochemical evaluation of the analytical properties toward oxygen detection of an FDA-approved, commercially available, clinical grade depth recording electrode comprising 12 Pt recording contacts. We found that the surface of the recording sites is composed of a thin film of smooth Pt and that the electrochemical behavior evaluated by cyclic voltammetry in acidic and neutral electrolyte is typical of polycrystalline Pt surface. The smoothness of the Pt surface was further corroborated by determination of the electrochemical active surface, confirming a roughness factor of 0.9. At an optimal working potential of −0.6 V vs. Ag/AgCl, the sensor displayed suitable values of sensitivity and limit of detection for in vivo PbtO₂ measurements. Based on the reported catalytical properties of Pt toward the electroreduction reaction of O₂, we propose that these probes could be repurposed for multisite monitoring of PbtO₂ in vivo in the human brain.

The influence of norepinephrine and phenylephrine on cerebral perfusion and oxygenation during propofol-remifentanil and propofol-remifentanil-dexmedetomidine anaesthesia in piglets

Background

Vasopressors are frequently used to increase blood pressure in order to ensure sufficient cerebral perfusion and oxygenation (CPO) during hypotensive periods in anaesthetized patients. Efficacy depends both on the vasopressor and anaesthetic protocol used. Propofol–remifentanil total intravenous anaesthesia (TIVA) is common in human anaesthesia, and dexmedetomidine is increasingly used as adjuvant to facilitate better haemodynamic stability and analgesia. Little is known of its interaction with vasopressors and subsequent effects on CPO. This study investigates the CPO response to infusions of norepinephrine and phenylephrine in piglets during propofol–remifentanil and propofol–remifentanil–dexmedetomidine anaesthesia. Sixteen healthy female piglets (25–34 kg) were randomly allocated into a two-arm parallel group design with either normal blood pressure (NBP) or induced low blood pressure (LBP). Anaesthesia was induced with propofol without premedication and maintained with propofol–remifentanil TIVA, and finally supplemented with continuous infusion of dexmedetomidine. Norepinephrine and phenylephrine were infused in consecutive intervention periods before and after addition of dexmedetomidine. Cerebral perfusion measured by laser speckle contrast imaging was related to cerebral oxygenation as measured by an intracerebral Licox probe (partial pressure of oxygen) and transcranial near infrared spectroscopy technology (NIRS) (cerebral oxygen saturation).

Results

During propofol–remifentanil anaesthesia, increases in blood pressure by norepinephrine and phenylephrine did not change cerebral perfusion significantly, but cerebral partial pressure of oxygen (Licox) increased following vasopressors in both groups and increases following norepinephrine were significant (NBP: P = 0.04, LBP: P = 0.02). In contrast, cerebral oxygen saturation (NIRS) fell significantly in NBP following phenylephrine (P = 0.003), and following both norepinephrine (P = 0.02) and phenylephrine (P = 0.002) in LBP. Blood pressure increase by both norepinephrine and phenylephrine during propofol–remifentanil–dexmedetomidine anaesthesia was not followed by significant changes in cerebral perfusion. Licox measures increased significantly following both vasopressors in both groups, whereas the decreases in NIRS measures were only significant in the NBP group.

Conclusions

Cerebral partial pressure of oxygen measured by Licox increased significantly in concert with the vasopressor induced increases in blood pressure in healthy piglets with both normal and low blood pressure. Cerebral oxygenation assessed by intracerebral Licox and transcranial NIRS showed opposing results to vasopressor infusions.

Electronic supplementary material

The online version of this article (10.1186/s13028-018-0362-z) contains supplementary material, which is available to authorized users.

The effect of dexmedetomidine on cerebral perfusion and oxygenation in healthy piglets with normal and lowered blood pressure anaesthetized with propofol-remifentanil total intravenous anaesthesia

BACKGROUND

During anaesthesia and surgery, in particular neurosurgery, preservation of cerebral perfusion and oxygenation (CPO) is essential for normal postoperative brain function. The isolated effects on CPO of either individual anaesthetic drugs or entire anaesthetic protocols are of importance in both clinical and research settings. Total intravenous anaesthesia (TIVA) with propofol and remifentanil is widely used in human neuroanaesthesia. In addition, dexmedetomidine is receiving increasing attention as an anaesthetic adjuvant in neurosurgical, intensive care, and paediatric patients. Despite the extensive use of pigs as animal models in neuroscience and the increasing use of both propofol-remifentanil and dexmedetomidine, very little is known about their combined effect on CPO in pigs with uninjured brains. This study investigates the effect of dexmedetomidine on CPO in piglets with normal and lowered blood pressure during background anaesthesia with propofol-remifentanil TIVA. Sixteen healthy female Danish pigs (crossbreeds of Danish Landrace, Yorkshire and Duroc, 25-34 kg) were used. Three animals were subsequently excluded. The animals were randomly allocated into one of two groups with either normal blood pressure (NBP, n = 6) or with induced low blood pressure (LBP, n = 7). Both groups were subjected to the same experimental protocol. Intravenous propofol induction was performed without premedication. Anaesthesia was maintained with propofol-remifentanil TIVA, and later supplemented with continuous infusion of dexmedetomidine. Assessments of cerebral perfusion obtained by laser speckle contrast imaging (LSCI) were related to cerebral oxygenation measures (PbrO2) obtained by an intracerebral Clark-type Licox probe.

RESULTS

Addition of dexmedetomidine resulted in a 32% reduction in median PbrO2 values for the LBP group (P = 0.03), but no significant changes in PbrO2 were observed for the NBP group. No significant changes in LSCI readings were observed in either group between any time points, despite a 28% decrease in the LBP group following dexmedetomidine administration. Caval block resulted in a significant (P = 0.02) reduction in median MAP from 68 mmHg (range 63-85) at PCB to 58 mmHg (range 53-63) in the LBP group, but no significant differences in either PbrO2 or LSCI were observed due to this intervention (P = 0.6 and P = 0.3 respectively).

CONCLUSIONS

Addition of dexmedetomidine to propofol-remifentanil TIVA resulted in a significant decrease in cerebral oxygenation (PbrO2) measurements in piglets with lowered blood pressure. Cerebral perfusion (LSCI) did not decrease significantly in this group. In piglets with normal blood pressure, no significant changes in cerebral perfusion or oxygenation were seen in response to addition of dexmedetomidine to the background anaesthesia.

Effect of propofol and remifentanil on cerebral perfusion and oxygenation in pigs: a systematic review

The objective of this review is to evaluate the existing literature with regard to the influence of propofol and remifentanil total intravenous anaesthesia (TIVA) on cerebral perfusion and oxygenation in healthy pigs. Anaesthesia has influence on cerebral haemodynamics and it is important not only in human but also in veterinary anaesthesia to preserve optimal regulation of cerebral haemodynamics. Propofol and remifentanil are widely used in neuroanaesthesia and are increasingly used in experimental animal studies. In translational models, the pig has advantages compared to small laboratory animals because of brain anatomy, metabolism, neurophysiological maturation, and cerebral haemodynamics. However, reported effects of propofol and remifentanil on cerebral perfusion and oxygenation in pigs have not been reviewed. An electronic search identified 99 articles in English. Title and abstract screening selected 29 articles for full-text evaluation of which 19 were excluded with reasons. Of the 10 peer-reviewed articles included for review, only three had propofol or remifentanil anaesthesia as the primary study objective and only two directly investigated the effect of anaesthesia on cerebral perfusion and oxygenation (CPO). The evidence evaluated in this systematic review is limited, not focused on propofol and remifentanil and possibly influenced by factors of potential importance for CPO assessment. In one study of healthy pigs, CPO measures were within normal ranges following propofol-remifentanil anaesthesia, and addition of a single remifentanil bolus did not affect regional cerebral oxygen saturation (rSO2). Even though the pool of evidence suggests that propofol and remifentanil alone or in combination have limited effects on CPO in healthy pigs, confirmative evidence is lacking.

Neuroprotective measures in children with traumatic brain injury

Traumatic brain injury (TBI) is a major cause of death and disability in children. Severe TBI is a leading cause of death and often leads to life changing disabilities in survivors. The modern management of severe TBI in children on intensive care unit focuses on preventing secondary brain injury to improve outcome. Standard neuroprotective measures are based on management of intracranial pressure (ICP) and cerebral perfusion pressure (CPP) to optimize the cerebral blood flow and oxygenation, with the intention to avoid and minimise secondary brain injury. In this article, we review the current trends in management of severe TBI in children, detailing the general and specific measures followed to achieve the desired ICP and CPP goals. We discuss the often limited evidence for these therapeutic interventions in children, extrapolation of data from adults, and current recommendation from paediatric guidelines. We also review the recent advances in understanding the intracranial physiology and neuroprotective therapies, the current research focus on advanced and multi-modal neuromonitoring, and potential new therapeutic and prognostic targets.

Monitoring of brain and systemic oxygenation in neurocritical care patients

Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.

A Prospective Randomized Study of Brain Tissue Oxygen Pressure-Guided Management in Moderate and Severe Traumatic Brain Injury Patients

The purpose of this study was to compare the effect of PbtO₂-guided therapy with traditional intracranial pressure- (ICP-) guided treatment on the management of cerebral variables, therapeutic interventions, survival rates, and neurological outcomes of moderate and severe traumatic brain injury (TBI) patients. From 2009 to 2010, TBI patients with a Glasgow coma scale <12 were recruited from 6 collaborative hospitals in northern Taiwan, excluding patients with severe systemic injuries, fixed and dilated pupils, and other major diseases. In total, 23 patients were treated with PbtO₂-guided management (PbtO₂ > 20 mmHg), and 27 patients were treated with ICP-guided therapy (ICP < 20 mmHg and CPP > 60 mmHg) in the neurosurgical intensive care unit (NICU); demographic characteristics were similar across groups. The survival rate in the PbtO₂-guided group was also significantly increased at 3 and 6 months after injury. Moreover, there was a significant correlation between the PbtO₂ signal and Glasgow outcome scale-extended in patients from 1 to 6 months after injury. This finding demonstrates that therapy directed by PbtO₂ monitoring is valuable for the treatment of patients with moderate and severe TBI and that increasing PaO₂ to 150 mmHg may be efficacious for preventing cerebral hypoxic events after brain trauma.

Elevated cerebral blood volume contributes to increased FLAIR signal in the cerebral sulci of propofol-sedated children

BACKGROUND AND PURPOSE

Hyperintense FLAIR signal in the cerebral sulci of anesthetized children is attributed to supplemental oxygen (fraction of inspired oxygen) but resembles FLAIR hypersignal associated with perfusion abnormalities in Moyamoya disease and carotid stenosis. We investigated whether cerebral perfusion, known to be altered by anesthesia, contributes to diffuse signal intensity in sulci in children and explored the relative contributions of supplemental oxygen, cerebral perfusion, and anesthesia to signal intensity in sulci.

MATERIALS AND METHODS

Supraventricular signal intensity in sulci on pre- and postcontrast T2 FLAIR images of 24 propofol-sedated children (6.20 ± 3.28 years) breathing supplemental oxygen and 18 nonsedated children (14.28 ± 2.08 years) breathing room air was graded from 0 to 3. The Spearman correlation of signal intensity in sulci with the fraction of inspired oxygen and age in 42 subjects, and with dynamic susceptibility contrast measures of cortical CBF, CBV, and MTT available in 25 subjects, were evaluated overall and compared between subgroups. Factors most influential on signal intensity in sulci were identified by stepwise logistic regression.

RESULTS

CBV was more influential on noncontrast FLAIR signal intensity in sulci than the fraction of inspired oxygen or age in propofol-sedated children (CBV: r = 0.612, P = .026; fraction of inspired oxygen: r = -0.418, P = .042; age: r = 0.523, P = .009) and overall (CBV: r = 0.671, P = .0002; fraction of inspired oxygen: r = 0.442, P = .003; age: r = -0.374, P = .015). MTT (CBV/CBF) was influential in the overall cohort (r = 0.461, P = .020). Signal intensity in sulci increased with contrast in 45% of subjects, decreased in none, and was greater (P < .0001) in younger propofol-sedated subjects, in whom the signal intensity in sulci increased with age postcontrast (r = .600, P = .002).

CONCLUSIONS

Elevated cortical CBV appears to contribute to increased signal intensity in sulci on noncontrast FLAIR in propofol-sedated children. The effects of propofol on age-related cerebral perfusion and vascular permeability may play a role.

Targeting p35/Cdk5 signalling via CIP-peptide promotes angiogenesis in hypoxia

Cyclin-dependent kinase-5 (Cdk5) is over-expressed in both neurons and microvessels in hypoxic regions of stroke tissue and has a significant pathological role following hyper-phosphorylation leading to calpain-induced cell death. Here, we have identified a critical role of Cdk5 in cytoskeleton/focal dynamics, wherein its activator, p35, redistributes along actin microfilaments of spreading cells co-localising with p(Tyr15)Cdk5, talin/integrin beta-1 at the lamellipodia in polarising cells. Cdk5 inhibition (roscovitine) resulted in actin-cytoskeleton disorganisation, prevention of protein co-localization and inhibition of movement. Cells expressing Cdk5 (D144N) kinase mutant, were unable to spread, migrate and form tube-like structures or sprouts, while Cdk5 wild-type over-expression showed enhanced motility and angiogenesis in vitro, which was maintained during hypoxia. Gene microarray studies demonstrated myocyte enhancer factor (MEF2C) as a substrate for Cdk5-mediated angiogenesis in vitro. MEF2C showed nuclear co-immunoprecipitation with Cdk5 and almost complete inhibition of differentiation and sprout formation following siRNA knock-down. In hypoxia, insertion of Cdk5/p25-inhibitory peptide (CIP) vector preserved and enhanced in vitro angiogenesis. These results demonstrate the existence of critical and complementary signalling pathways through Cdk5 and p35, and through which coordination is a required factor for successful angiogenesis in sustained hypoxic condition.

Brain tissue oxygenation and cerebral perfusion pressure thresholds of ischemia in a standardized pig brain death model

BACKGROUND

Neurointensive care of traumatic brain injury (TBI) patients is currently based on intracranial pressure (ICP) and cerebral perfusion pressure (CPP) targeted protocols. Monitoring brain tissue oxygenation (BtipO2) is of considerable clinical interest, but the exact threshold level of ischemia has been difficult to establish due to the complexity of the clinical situation. The objective of this study was to use the Neurovent-PTO (NV) probe, and to define critical cerebral oxygenation- and CPP threshold levels of cerebral ischemia in a standardized brain death model caused by increasing the ICP in pig. Ischemia was defined by a severe increase of cerebral microdialysis (MD) lactate/pyruvate ratio (L/P ratio > 30).

METHODS

BtipO2, L/P ratio, Glucose, Glutamate, Glycerol and CPP were recorded using NV and MD probes during gradual increase of ICP by inflation of an epidural balloon catheter with saline until brain death was achieved.

RESULTS

Baseline level of BtipO2 was 22.9 ± 6.2 mmHg, the L/P ratio 17.7 ± 6.1 and CPP 73 ± 17 mmHg. BtipO2 and CPP decreased when intracranial volume was added. The L/P ratio increased above its ischemic levels, (>30)when CPP decreased below 30 mmHg and BtipO2 to <10 mmHg.

CONCLUSIONS

A severe increase of ICP leading to CPP below 30 mmHg and BtipO2 below 10 mmHg is associated with an increase of the L/P ratio, thus seems to be critical thresholds for cerebral ischemia under these conditions.

Advanced neuromonitoring and imaging in pediatric traumatic brain injury

While the cornerstone of monitoring following severe pediatric traumatic brain injury is serial neurologic examinations, vital signs, and intracranial pressure monitoring, additional techniques may provide useful insight into early detection of evolving brain injury. This paper provides an overview of recent advances in neuromonitoring, neuroimaging, and biomarker analysis of pediatric patients following traumatic brain injury.

Comparison between cerebral tissue oxygen tension and energy metabolism in experimental subdural hematoma

BACKGROUND

An experimental swine model (n = 7) simulating an acute subdural hematoma (ASDH) was employed (1) to explore the relation between the brain tissue oxygenation (PbtO(2)) and the regional cerebral energy metabolism as obtained by microdialysis, and (2) to define the lowest level of PbtO(2) compatible with intact energy metabolism.

METHODS

ASDH was produced by infusion of 7 ml of autologous blood (infusion rate 0.5 ml/min) by a catheter placed subdurally. PbtO(2) and microdialysis probes were placed symmetrically in the injured ("bad-side") and non-injured ("good-side") hemispheres. Intracranial pressure (ICP) was monitored in the "good-side."

RESULTS

ICP, cerebral perfusion pressure (CPP), PbtO(2), glucose, lactate, pyruvate, lactate-pyruvate ratio (LP ratio), glutamate, and glycerol were recorded at baseline (60 min) and post trauma (360 min). After the creation of the ASDH, PbtO(2) decreased significantly in both the hemispheres (P < 0.001). No significant difference was found between the sides post trauma. The LP ratio, glutamate, and glycerol in the "bad-side" increased significantly over the "good-side" where the values remained within the normal limits. A PbtO(2) value below approximately 25 mmHg was found to be associated with disturbed energy metabolism in the "bad-side" but not in the "good-side." No correlation was found between the LP ratio and PbtO(2) in either hemisphere.

CONCLUSIONS

PbtO(2) monitoring accurately describes tissue oxygenation but does not disclose whether the oxygen delivery is sufficient for maintaining cerebral energy metabolism. Accordingly, it may not be possible to define a threshold level for PbtO(2) below which energy failure and permanent tissue damage occurs.

Cerebral tissue oxygenation measured by two different probes: challenges and interpretation

PURPOSE

Cerebral tissue oxygenation (PbrO(2)) is most frequently monitored using a Licox CC1.SB system (LX, Integra Neuroscience, France) but recently a new probe--the Neurovent-PTO (NV)--was introduced by a different manufacturer (Raumedic, Germany). There are no prospective data on how these probes compare in clinical routine. We therefore compared both probes in comatose patients suffering from traumatic brain injury (TBI) or subarachnoid haemorrhage (SAH) during dynamic changes of inspirational oxygen fraction (FiO(2)) and mean arterial pressure (MAP).

METHODS

PbrO(2) in 11 patients was recorded continuously using an LX and NV probe placed side by side into the same cerebrovascular region. Once a steady baseline value was reached FiO(2) was increased by 20% for 10 min. Once the baseline values were re-established MAP was increased by 20 mmHg for 10 min. Evaluation was performed using a four-parameter logistic function and Bland-Altman analyses.

RESULTS

PbrO(2) values of both probes differed significantly at all times. The LX probe reacted significantly faster to changes in FiO(2) and MAP. Limits of agreement ranged between -32.1 and 20.0 mmHg. Mean LX values were 6.1 mmHg lower than NV values.

CONCLUSIONS

Since the examined patient cohort was rather small, this study's results are preliminary. However, they suggest that LX and NV probes measure different PbrO(2) values in routine monitoring as well as during phases of dynamic changes in FiO(2) and MAP. These data therefore do not support the view that both probes can be used interchangeably.

Quantitative tissue oxygen measurement in multiple organs using 19F MRI in a rat model

Measurement of individual organ tissue oxygen levels can provide information to help evaluate and optimize medical interventions in many areas including wound healing, resuscitation strategies, and cancer therapeutics. Echo planar (19) F MRI has previously focused on tumor oxygen measurement at low oxygen levels (pO(2)) <30 mmHg. It uses the linear relationship between spin-lattice relaxation rate (R(1)) of hexafluorobenzene (HFB) and pO(2). The feasibility of this technique for a wider range of pO(2) values and individual organ tissue pO(2) measurement was investigated in a rat model. Spin-lattice relaxation times (T(1) = 1/R(1)) of hexafluorobenzene were measured using (19) F saturation recovery echo planar imaging. Initial in vitro studies validated the linear relationship between R(1) and pO(2) from 0 to 760 mmHg oxygen partial pressure at 25, 37, and 41°C at 7 Tesla for hexafluorobenzene. In vivo experiments measured rat tissue oxygen (ptO2) levels of brain, kidney, liver, gut, muscle, and skin during inhalation of both 30 and 100% oxygen. All organ ptO(2) values significantly increased with hyperoxia (P < 0.001). This study demonstrates that (19) F MRI of hexafluorobenzene offers a feasible tool to measure regional ptO2 in vivo, and that hyperoxia significantly increases ptO2 of multiple organs in a rat model.

Corrosion of tungsten microelectrodes used in neural recording applications

In neuroprosthetic applications, long-term electrode viability is necessary for robust recording of the activity of neural populations used for generating communication and control signals. The corrosion of tungsten microwire electrodes used for intracortical recording applications was analyzed in a controlled bench-top study and compared to the corrosion of tungsten microwires used in an in vivo study. Two electrolytes were investigated for the bench-top electrochemical analysis: 0.9% phosphate buffered saline (PBS) and 0.9% PBS containing 30 mM of hydrogen peroxide. The oxidation and reduction reactions responsible for corrosion were found by measurement of the open circuit potential and analysis of Pourbaix diagrams. Dissolution of tungsten to form the tungstic ion was found to be the corrosion mechanism. The corrosion rate was estimated from the polarization resistance, which was extrapolated from the electrochemical impedance spectroscopy data. The results show that tungsten microwires in an electrolyte of PBS have a corrosion rate of 300-700 μm/yr. The corrosion rate for tungsten microwires in an electrolyte containing PBS and 30 mM H₂O₂ is accelerated to 10,000-20,000 μm/yr. The corrosion rate was found to be controlled by the concentration of the reacting species in the cathodic reaction (e.g. O₂ and H₂O₂). The in vivo corrosion rate, averaged over the duration of implantation, was estimated to be 100 μm/yr. The reduced in vivo corrosion rate as compared to the bench-top rate is attributed to decreased rate of oxygen diffusion caused by the presence of a biological film and a reduced concentration of available oxygen in the brain.

Oxygen, a Key Factor Regulating Cell Behavior during Neurogenesis and Cerebral Diseases

Oxygen is vital to maintain the normal functions of almost all the organs, especially for brain which is one of the heaviest oxygen consumers in the body. The important roles of oxygen on the brain are not only reflected in the development, but also showed in the pathological processes of many cerebral diseases. In the current review, we summarized the oxygen levels in brain tissues tested by real-time measurements during the embryonic and adult neurogenesis, the cerebral diseases, or in the hyperbaric/hypobaric oxygen environment. Oxygen concentration is low in fetal brain (0.076-7.6 mmHg) and in adult brain (11.4-53.2 mmHg), decreased during stroke, and increased in hyperbaric oxygen environment. In addition, we reviewed the effects of oxygen tensions on the behaviors of neural stem cells (NSCs) in vitro cultures at different oxygen concentration (15.2-152 mmHg) and in vivo niche during different pathological states and in hyperbaric/hypobaric oxygen environment. Moderate hypoxia (22.8-76 mmHg) can promote the proliferation of NSCs and enhance the differentiation of NSCs into the TH-positive neurons. Next, we briefly presented the oxygen-sensitive molecular mechanisms regulating NSCs proliferation and differentiation recently found including the Notch, Bone morphogenetic protein and Wnt pathways. Finally, the future perspectives about the roles of oxygen on brain and NSCs were given.

Cerebral perfusion pressure thresholds for brain tissue hypoxia and metabolic crisis after poor-grade subarachnoid hemorrhage

BACKGROUND AND PURPOSE

To identify a minimally acceptable cerebral perfusion pressure threshold above which the risks of brain tissue hypoxia (BTH) and oxidative metabolic crisis are reduced for patients with subarachnoid hemorrhage (SAH).

METHODS

We studied 30 poor-grade SAH patients who underwent brain multimodality monitoring (3042 hours). Physiological measures were averaged over 60 minutes for each collected microdialysis sample. Metabolic crisis was defined as a lactate/pyruvate ratio>40 with a brain glucose concentration≤0.7 mmol/L. BTH was defined as PbtO2<20 mm Hg. Outcome was assessed at 3 months with the Modified Rankin Scale.

RESULTS

Multivariable analyses adjusting for admission Hunt-Hess grade, intraventricular hemorrhage, systemic glucose, and end-tidal CO2 revealed that cerebral perfusion pressure≤70 mm Hg was significantly associated with an increased risk of BTH (OR, 2.0; 95% CI, 1.2-3.3; P=0.007) and metabolic crisis (OR, 2.1; 95% CI, 1.2-3.7; P=0.007). Death or severe disability at 3 months was significantly associated with metabolic crisis (OR, 5.4; 95% CI, 1.8-16; P=0.002) and BTH (OR, 5.1; 95% CI, 1.2-23; P=0.03) after adjusting for admission Hunt-Hess grade.

CONCLUSIONS

Metabolic crisis and BTH are associated with mortality and poor functional recovery after SAH. Cerebral perfusion pressure levels<70 mm Hg was associated with metabolic crisis and BTH, and may increase the risk of secondary brain injury in poor-grade SAH patients.

The physiology behind direct brain oxygen monitors and practical aspects of their use

INTRODUCTION

Secondary neuronal injury is implicated in poor outcome after acute neurological insults. Outcome can be improved with protocol-driven therapy. These therapies have largely been based on monitoring and control of intracranial pressure and the maintenance of an adequate cerebral perfusion pressure.

DISCUSSION

In recent years, brain tissue oxygen partial pressure (PbtO2) monitoring has emerged as a clinically useful modality and a complement to intracranial pressure monitors. This review examines the physiology of PbtO2 monitors and practical aspects of their use.

Methods of monitoring brain oxygenation

INTRODUCTION

Posttraumatic brain ischemia or hypoxia is a major potential cause of secondary injury that may lead to poor outcome. Avoidance, or amelioration, of this secondary injury depends on early diagnosis and intervention before permanent injury occurs. However, tools to monitor brain oxygenation continuously in the neuro-intensive care unit have been lacking.

DISCUSSION

In recent times, methods of monitoring aspects of brain oxygenation continuously by the bedside have been evaluated in several experimental and clinical series and are potentially changing the way we manage head-injured patients. These monitors have the potential to alert the clinician to possible secondary injury and enable intervention, help interpret pathophysiological changes (e.g., hyperemia causing raised intracranial pressure), monitor interventions (e.g., hyperventilation for increased intracranial pressure), and prognosticate. This review focuses on jugular venous saturation, brain tissue oxygen tension, and near-infrared spectroscopy as practical methods that may have an important role in managing patients with brain injury, with a particular focus on the available evidence in children. However, to use these monitors effectively and to understand the studies in which these monitors are employed, it is important for the clinician to appreciate the technical characteristics of each monitor, as well as respective strengths and limitations of each. It is equally important that the clinician understands relevant aspects of brain oxygen physiology and head trauma pathophysiology to enable correct interpretation of the monitored data and therefore to direct an appropriate therapeutic response that is likely to benefit, not harm, the patient.

Simultaneous measurement of brain tissue oxygen partial pressure, temperature, and global oxygen consumption during hibernation, arousal, and euthermy in non-sedated and non-anesthetized Arctic ground squirrels

This study reports an online temperature correction method for determining tissue oxygen partial pressure P(tO2) in the striatum and a novel simultaneous measurement of brain P(tO2) and temperature (T(brain)) in conjunction with global oxygen consumption V(O2) in non-sedated and non-anesthetized freely moving Arctic ground squirrels (AGS, Spermophilus parryii). This method fills an important research gap-the lack of a suitable method for physiologic studies of tissue P(O2) in hibernating or other cool-blooded species. P(tO2) in AGS brain during euthermy (21.22+/-2.06 mmHg) is significantly higher (P=0.016) than during hibernation (13.21+/-0.46 mmHg) suggests brain oxygenation in the striatum is normoxic during euthermy and hypoxic during hibernation. These results in P(tO2) are different from blood oxygen partial pressure P(aO2) in AGS, which are significantly lower during euthermy than during hibernation and are actually hypoxic during euthermy and normoxic during hibernation in our previous study. This intriguing difference between the P(O2) of brain tissue and blood during these two physiological states suggests that regional mechanisms in the brain play a role in maintaining tissue oxygenation and protect against hypoxia during hibernation.

NICEM consensus on neurological monitoring in acute neurological disease

This manuscript summarises the consensus on neuromonitoring in neuro-intensive care promoted and organised by the Neuro-Intensive Care and Emergency Medicine (NICEM) Section of the European Society of Intensive Care Medicine (ESICM). It is expected that continuous monitoring using multi-modal techniques will help to overcome the limitations of each individual method and will provide a better diagnosis. More specific treatment can then be applied; however, it remains to be determined which combination of parameters is optimal. The questions discussed and addressed in this manuscript are: (1) Who should have ICP monitoring and for how long? (2) What ICP technologies are available and what are their relative advantages/disadvantages? (3) Should CPP monitoring and autoregulation testing be used? (4) When should brain tissue oxygen tension (PbrO(2)) be monitored? (5) Should structurally normal or abnormal tissue be monitored with PbrO(2)? (6) Should microdialysis be considered in complex cases? It is hoped that this document will prove useful to clinicians working in NICU and also to those developing specialist NICU services within their hospital practice.

Monitoring brain tissue oxygen tension in brain-injured patients reveals hypoxic episodes in normal-appearing and in peri-focal tissue

OBJECTIVE

We compared brain tissue oxygen tension (PtiO2) measured in peri-focal and in normal-appearing brain parenchyma on computerized tomography (CT) in patients following traumatic brain injury (TBI).

DESIGN

Prospective observational study.

SETTING

Neurointensive care unit.

PATIENTS AND PARTICIPANTS

Thirty-two consecutive TBI patients were subjected to PtiO2 monitoring.

INTERVENTIONS

Peri-focal tissue was identified by the presence of a hypodense area of the contusion and/or within 1 cm from the core of the contusion. The position of the tip of the PtiO2 probe was assessed at follow-up CT scan.

MEASUREMENTS AND RESULTS

Mean PtiO2 in the peri-contusional tissue was 19.7+/-2.1 mmHg and was lower than PtiO2 in normal-appearing tissue (25.5+/-1.5 mmHg, p < 0.05), despite a greater cerebral perfusion pressure (CPP) (73.7+/-2.3 mmHg vs. 67.4+/-1.4 mmHg, p < 0.05). We observed both in peri-focal tissue and in normal-appearing tissue episodes of brain hypoxia (PtiO2 < 20 mmHg for at least 10 min), whose median duration was longer in peri-focal tissue than in normal-appearing tissue (51% vs. 34% of monitoring time, p < 0.01). In peri-focal tissue, we observed a progressive PtiO2 increase from pathologic to normal values (p < 0.01).

CONCLUSIONS

Multiple episodes of brain hypoxia occurred over the first 5 days following severe TBI. PtiO2 was lower in peri-contusional tissue than in normal-appearing tissue. In peri-contusional tissue, a progressive increase of PtiO2 from pathologic to normal values was observed over time, suggestive of an improvement at microcirculatory level.

Neuromonitoring in the intensive care unit. II. Cerebral oxygenation monitoring and microdialysis

BACKGROUND

Monitoring the injured brain is an integral part of the management of severely brain injured patients in intensive care. There is increasing interest in methods to monitor global and regional cerebral oxygenation. There have been significant advances in analysing tissue oxygenation and local metabolites in the injured brain over the past decade.

DISCUSSION

Cerebral oxygenation can be assessed on a global or regional basis by jugular venous oximetry and near infra-red spectroscopy respectively. Techniques of brain tissue oxygenation monitoring and microdialysis are also covered in this review.

CONCLUSIONS

Various modalities are available to monitor oxygenation and the local milieu in the injured brain in the intensive care unit. Use of these modalities helps to optimise brain oxygen delivery and metabolism in patients with acute brain injury.

Determining critical values of calculated parameters within a physiologic model

To determine the critical value of calculated but not readily measurable variables of a physiologic model, we examine clinical studies of similar variables and establish the critical values. The calculated variables considered in this study are the partial pressure of oxygen in the myocardium and in the gray matter of the brain. Partial pressure target values of 29 mmHg for cerebral tissue and 23 mmHg for myocardial tissue were determined to be suitable for a critical threshold. We validated these with a physiologic model test by ensuring that these corresponded to a reasonable value of cardiac output, vital sign commonly used to evaluate patient well being. These values can be used for future analysis of physiologic monitors' alarm systems when using physiologic models.

Direct cerebral oxygenation monitoring--a systematic review of recent publications

This review has been compiled to assess publications related to the clinical application of direct cerebral tissue oxygenation (PtiO2) monitoring published in international, peer-reviewed scientific journals. Its goal was to extract relevant, i.e. positive and negative information on indications, clinical application, safety issues and impact on clinical situations as well as treatment strategies in neurosurgery, neurosurgical anaesthesiology, neurosurgical intensive care, neurology and related specialties. For completeness' sake it also presents some related basic science research. PtiO2 monitoring technology is a safe and valuable cerebral monitoring device in neurocritical care. Although a randomized outcome study is not available its clinical utility has repeatedly been clearly confirmed because it adds a monitoring parameter, independent from established cerebral monitoring devices. It offers new insights into cerebral physiology and pathophysiology. Pathologic values have been established in peer-reviewed research, which are not only relevant to outcome but are treatable. The benefits clearly outweigh the risks, which remains unchallenged in all publications retrieved. It is particularly attractive because it offers continuous, real-time data and is available at the bedside.

Mannitol decreases ICP but does not improve brain-tissue pO2 in severely head-injured patients with intracranial hypertension

Little is known about the effect of post-traumatic mannitol infusion on cerebral metabolism and oxygenation. The purpose of this study was to investigate the effects of mannitol in comatose patients on PtiO2, PtiCO2 and brain tissue pH using Clark-type electrodes implanted into cerebral white matter. In the neurosurgical intensive care unit PtiO2, PtiCO2, brain tissue pH, arterial blood pressure, intracranial pressure (ICP), cerebral perfusion pressure (CPP) and jugular bulb oxygen saturation (SjvO2) were prospectively studied in eleven patients with severe traumatic brain injury (TBI) during a total of 30 mannitol administrations (125 ml of 20% Mannitol infused over 30 min through a central vein). When the initial ICP before mannitol infusion was below 20 mmHg neither ICP nor any of the other parameters changed significantly during or after mannitol infusion. With a pre-infusion ICP above 20 mmHg a significant effect was seen on ICP (decrease from 23 +/- 1 to 16 +/- 2 mmHg at 60 min) and CPP (increase from 68 +/- 2 to 80 +/- 3 mmHg at 120 min). These effects were not reflected in PtiO2 or SjvO2, which were 29 +/- 4 mmHg and 61 +/- 3%, respectively, at the beginning of mannitol injection and remained unchanged during the observation period. PtiCO2 and brain tissue pH were not affected by mannitol infusion. Future studies should focus on the identification of ICP or CPP thresholds where infusion of mannitol may actually improve O2-supply to the brain.

Multimodal monitoring in neurointensive care

Images