1
|
Jeffcote T, Lu KY, Lewis P, Gantner D, Battistuzzo CR, Udy AA. Brain tissue oxygen monitoring in moderate-to-severe traumatic brain injury: Physiological determinants, clinical interventions and current randomised controlled trial evidence. CRIT CARE RESUSC 2024; 26:204-209. [PMID: 39355499 PMCID: PMC11440050 DOI: 10.1016/j.ccrj.2024.05.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2024] [Revised: 05/23/2024] [Accepted: 05/30/2024] [Indexed: 10/03/2024]
Abstract
Modern intensive care for moderate-to-severe traumatic brain injury (msTBI) focuses on managing intracranial pressure (ICP) and cerebral perfusion pressure (CPP). This approach lacks robust clinical evidence and often overlooks the impact of hypoxic injuries. Emerging monitoring modalities, particularly those capable of measuring brain tissue oxygen, represent a promising avenue for advanced neuromonitoring. Among these, brain tissue oxygen tension (PbtO2) shows the most promising results. However, there is still a lack of consensus regarding the interpretation of PbtO2 in clinical practice. This review aims to provide an overview of the pathophysiological rationales, monitoring technology, physiological determinants, and recent clinical trial evidence for PbtO2 monitoring in the management of msTBI.
Collapse
Affiliation(s)
- Toby Jeffcote
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Kuan-Ying Lu
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Philip Lewis
- Office of the Deputy Vice-Chancellor, Enterprise and Engagement, Monash University, Australia
| | - Dashiell Gantner
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| | - Camila R Battistuzzo
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
| | - Andrew A Udy
- Australian and New Zealand Intensive Care Research Centre, School of Public Health and Preventive Medicine, Monash University, Melbourne, VIC, Australia
- Department of Intensive Care and Hyperbaric Medicine, The Alfred Hospital, Melbourne, VIC, Australia
| |
Collapse
|
2
|
Ramos MB, Britz JPE, Telles JPM, Nager GB, Cenci GI, Rynkowski CB, Teixeira MJ, Figueiredo EG. The Effects of Head Elevation on Intracranial Pressure, Cerebral Perfusion Pressure, and Cerebral Oxygenation Among Patients with Acute Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2024:10.1007/s12028-024-02020-3. [PMID: 38886326 DOI: 10.1007/s12028-024-02020-3] [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: 07/16/2023] [Accepted: 05/23/2024] [Indexed: 06/20/2024]
Abstract
BACKGROUND Head elevation is recommended as a tier zero measure to decrease high intracranial pressure (ICP) in neurocritical patients. However, its quantitative effects on cerebral perfusion pressure (CPP), jugular bulb oxygen saturation (SjvO2), brain tissue partial pressure of oxygen (PbtO2), and arteriovenous difference of oxygen (AVDO2) are uncertain. Our objective was to evaluate the effects of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2 among patients with acute brain injury. METHODS We conducted a systematic review and meta-analysis on PubMed, Scopus, and Cochrane Library of studies comparing the effects of different degrees of head elevation on ICP, CPP, SjvO2, PbtO2, and AVDO2. RESULTS A total of 25 articles were included in the systematic review. Of these, 16 provided quantitative data regarding outcomes of interest and underwent meta-analyses. The mean ICP of patients with acute brain injury was lower in group with 30° of head elevation than in the supine position group (mean difference [MD] - 5.58 mm Hg; 95% confidence interval [CI] - 6.74 to - 4.41 mm Hg; p < 0.00001). The only comparison in which a greater degree of head elevation did not significantly reduce the ICP was 45° vs. 30°. The mean CPP remained similar between 30° of head elevation and supine position (MD - 2.48 mm Hg; 95% CI - 5.69 to 0.73 mm Hg; p = 0.13). Similar findings were observed in all other comparisons. The mean SjvO2 was similar between the 30° of head elevation and supine position groups (MD 0.32%; 95% CI - 1.67% to 2.32%; p = 0.75), as was the mean PbtO2 (MD - 1.50 mm Hg; 95% CI - 4.62 to 1.62 mm Hg; p = 0.36), and the mean AVDO2 (MD 0.06 µmol/L; 95% CI - 0.20 to 0.32 µmol/L; p = 0.65).The mean ICP of patients with traumatic brain injury was also lower with 30° of head elevation when compared to the supine position. There was no difference in the mean values of mean arterial pressure, CPP, SjvO2, and PbtO2 between these groups. CONCLUSIONS Increasing degrees of head elevation were associated, in general, with a lower ICP, whereas CPP and brain oxygenation parameters remained unchanged. The severe traumatic brain injury subanalysis found similar results.
Collapse
Affiliation(s)
- Miguel Bertelli Ramos
- Department Neurosurgery, Hospital Do Servidor Público Estadual de São Paulo, São Paulo, Brazil
| | - João Pedro Einsfeld Britz
- Department of Neurosurgery, Hospital Cristo Redentor, Grupo Hospitalar Conceição, Porto Alegre, Brazil
| | | | - Gabriela Borges Nager
- School of Medicine, Universidade Federal Do Estado Do Rio de Janeiro, Rio de Janeiro, Brazil
| | | | | | | | | |
Collapse
|
3
|
Svedung Wettervik T, Beqiri E, Hånell A, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury-part II: isolated and combined insults in relation to outcome. Crit Care 2023; 27:370. [PMID: 37752602 PMCID: PMC10523606 DOI: 10.1186/s13054-023-04659-4] [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: 07/25/2023] [Accepted: 09/22/2023] [Indexed: 09/28/2023] Open
Abstract
BACKGROUND The primary aim was to explore the concept of isolated and combined threshold-insults for brain tissue oxygenation (pbtO2) in relation to outcome in traumatic brain injury (TBI). METHODS A total of 239 TBI patients with data on clinical outcome (GOS) and intracranial pressure (ICP) and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Outcome was dichotomised into favourable/unfavourable (GOS 4-5/1-3) and survival/mortality (GOS 2-5/1). PbtO2 was studied over the entire monitoring period. Thresholds were analysed in relation to outcome based on median and mean values, percentage of time and dose per hour below critical values and visualised as the combined insult intensity and duration. RESULTS Median pbtO2 was slightly, but not significantly, associated with outcome. A pbtO2 threshold at 25 and 20 mmHg, respectively, yielded the highest x2 when dichotomised for favourable/unfavourable outcome and mortality/survival in chi-square analyses. A higher dose and higher percentage of time spent with pbtO2 below 25 mmHg as well as lower thresholds were associated with unfavourable outcome, but not mortality. In a combined insult intensity and duration analysis, there was a transition from favourable towards unfavourable outcome when pbtO2 went below 25-30 mmHg for 30 min and similar transitions occurred for shorter durations when the intensity was higher. Although these insults were rare, pbtO2 under 15 mmHg was more strongly associated with unfavourable outcome if, concurrently, ICP was above 20 mmHg, cerebral perfusion pressure below 60 mmHg, or pressure reactivity index above 0.30 than if these variables were not deranged. In a multiple logistic regression, a higher percentage of monitoring time with pbtO2 < 15 mmHg was associated with a higher rate of unfavourable outcome. CONCLUSIONS Low pbtO2, under 25 mmHg and particularly below 15 mmHg, for longer durations and in combination with disturbances in global cerebral physiological variables were associated with poor outcome and may indicate detrimental ischaemic hypoxia. Prospective trials are needed to determine if pbtO2-directed therapy is beneficial, at what individualised pbtO2 threshold therapies are warranted, and how this may depend on the presence/absence of concurrent cerebral physiological disturbances.
Collapse
Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, University of Cambridge, Cambridge, UK
| |
Collapse
|
4
|
Svedung Wettervik T, Beqiri E, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury: part I-To what extent does PbtO 2 reflect global cerebral physiology? Crit Care 2023; 27:339. [PMID: 37653526 PMCID: PMC10472704 DOI: 10.1186/s13054-023-04627-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The primary aim was to explore the association of global cerebral physiological variables including intracranial pressure (ICP), cerebrovascular reactivity (PRx), cerebral perfusion pressure (CPP), and deviation from the PRx-based optimal CPP value (∆CPPopt; actual CPP-CPPopt) in relation to brain tissue oxygenation (pbtO2) in traumatic brain injury (TBI). METHODS A total of 425 TBI patients with ICP- and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Generalized additive models (GAMs) and linear mixed effect models were used to explore the association of ICP, PRx, CPP, and CPPopt in relation to pbtO2. PbtO2 < 20 mmHg, ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, and ∆CPPopt < - 5 mmHg were considered as cerebral insults. RESULTS PbtO2 < 20 mmHg occurred in median during 17% of the monitoring time and in less than 5% in combination with ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, or ∆CPPopt < - 5 mmHg. In GAM analyses, pbtO2 remained around 25 mmHg over a large range of ICP ([0;50] mmHg) and PRx [- 1;1], but deteriorated below 20 mmHg for extremely low CPP below 30 mmHg and ∆CPPopt below - 30 mmHg. In linear mixed effect models, ICP, CPP, PRx, and ∆CPPopt were significantly associated with pbtO2, but the fixed effects could only explain a very small extent of the pbtO2 variation. CONCLUSIONS PbtO2 below 20 mmHg was relatively frequent and often occurred in the absence of disturbances in ICP, PRx, CPP, and ∆CPPopt. There were significant, but weak associations between the global cerebral physiological variables and pbtO2, suggesting that hypoxic pbtO2 is often a complex and independent pathophysiological event. Thus, other variables may be more crucial to explain pbtO2 and, likewise, pbtO2 may not be a suitable outcome measure to determine whether global cerebral blood flow optimization such as CPPopt therapy is successful.
Collapse
Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| |
Collapse
|
5
|
Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
Collapse
Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
| |
Collapse
|
6
|
Hays LM, Udy A, Adamides AA, Anstey JR, Bailey M, Bellapart J, Byrne K, Cheng A, Jamie Cooper D, Drummond KJ, Haenggi M, Jakob SM, Higgins AM, Lewis PM, Hunn MK, McNamara R, Menon DK, Murray L, Reddi B, Trapani T, Vallance S, Young PJ, Diaz-Arrastia R, Shutter L, Murray PT, Curley GF, Nichol A. Effects of brain tissue oxygen (PbtO2) guided management on patient outcomes following severe traumatic brain injury: A systematic review and meta-analysis. J Clin Neurosci 2022; 99:349-358. [DOI: 10.1016/j.jocn.2022.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022]
|
7
|
Casault C, Couillard P, Kromm J, Rosenthal E, Kramer A, Brindley P. Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners. J Intensive Care Soc 2022; 23:191-202. [PMID: 35615230 PMCID: PMC9125434 DOI: 10.1177/1751143720980273] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Traumatic brain injury (TBI) is common and potentially devastating. Traditional examination-based patient monitoring following TBI may be inadequate for frontline clinicians to reduce secondary brain injury through individualized therapy. Multimodal neurologic monitoring (MMM) offers great potential for detecting early injury and improving outcomes. By assessing cerebral oxygenation, autoregulation and metabolism, clinicians may be able to understand neurophysiology during acute brain injury, and offer therapies better suited to each patient and each stage of injury. Hence, we offer this primer on brain tissue oxygen monitoring, pressure reactivity index monitoring and cerebral microdialysis. This narrative review serves as an introductory guide to the latest clinically-relevant evidence regarding key neuromonitoring techniques.
Collapse
Affiliation(s)
- Colin Casault
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
| | - Philippe Couillard
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Julie Kromm
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Eric Rosenthal
- Department of Critical Care
Medicine, University of Alberta, Edmonton, Canada
| | - Andreas Kramer
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Peter Brindley
- Department of Neurology, Harvard
University, Boston, MA, USA
| |
Collapse
|
8
|
Herculano-Houzel S, Rothman DL. From a Demand-Based to a Supply-Limited Framework of Brain Metabolism. Front Integr Neurosci 2022; 16:818685. [PMID: 35431822 PMCID: PMC9012138 DOI: 10.3389/fnint.2022.818685] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022] Open
Abstract
What defines the rate of energy use by the brain, as well as per neurons of different sizes in different structures and animals, is one fundamental aspect of neuroscience for which much has been theorized, but very little data are available. The prevalent theories and models consider that energy supply from the vascular system to different brain regions is adjusted both dynamically and in the course of development and evolution to meet the demands of neuronal activity. In this perspective, we offer an alternative view: that regional rates of energy use might be mostly constrained by supply, given the properties of the brain capillary network, the highly stable rate of oxygen delivery to the whole brain under physiological conditions, and homeostatic constraints. We present evidence that these constraints, based on capillary density and tissue oxygen homeostasis, are similar between brain regions and mammalian species, suggesting they derive from fundamental biophysical limitations. The same constraints also determine the relationship between regional rates of brain oxygen supply and usage over the full physiological range of brain activity, from deep sleep to intense sensory stimulation, during which the apparent uncoupling of blood flow and oxygen use is still a predicted consequence of supply limitation. By carefully separating "energy cost" into energy supply and energy use, and doing away with the problematic concept of energetic "demands," our new framework should help shine a new light on the neurovascular bases of metabolic support of brain function and brain functional imaging. We speculate that the trade-offs between functional systems and even the limitation to a single attentional spot at a time might be consequences of a strongly supply-limited brain economy. We propose that a deeper understanding of brain energy supply constraints will provide a new evolutionary understanding of constraints on brain function due to energetics; offer new diagnostic insight to disturbances of brain metabolism; lead to clear, testable predictions on the scaling of brain metabolic cost and the evolution of brains of different sizes; and open new lines of investigation into the microvascular bases of progressive cognitive loss in normal aging as well as metabolic diseases.
Collapse
Affiliation(s)
- Suzana Herculano-Houzel
- Department of Psychology, Vanderbilt University, Nashville, TN, United States
- Department of Biological Sciences, Vanderbilt University, Nashville, TN, United States
- Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, United States
| | - Douglas L. Rothman
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, United States
- Department of Biomedical Engineering, Yale University, New Haven, CT, United States
- Magnetic Resonance Research Center, Yale University, New Haven, CT, United States
| |
Collapse
|
9
|
Picetti E, Bouzat P, Cattani L, Taccone FS. Perioperative management of severe brain injured patients. Minerva Anestesiol 2021; 88:380-389. [PMID: 34636222 DOI: 10.23736/s0375-9393.21.15927-9] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/08/2022]
Abstract
Traumatic brain injury (TBI) is a leading cause of mortality and disability worldwide. Head injured patients may frequently require emergency neurosurgery. The perioperative TBI period is very important as many interventions done in this stage can have a profound effect on the long-term neurological outcome. This practical concise narrative review focused mainly on: 1) the management of severe TBI patients with neurosurgical lesions admitted to a spoke center (i.e. hospital without neurosurgery) and therefore needing a transfer to the hub center (i.e. hospital with neurosurgery); 2) the management of severe TBI patients with intracranial hypertension/brain herniation awaiting for neurosurgery and 3) the neuromonitoring-oriented management in the immediate post-operative period. The proposals presented in this review mainly apply to severe TBI patients admitted to high-income countries.
Collapse
Affiliation(s)
- Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy -
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care Medicine, Grenoble Alps Trauma Centre, Grenoble Alpes University Hospital, Grenoble, France
| | - Luca Cattani
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | - Fabio S Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Brussels, Belgium
| |
Collapse
|
10
|
Ngo MT, Harley BAC. Progress in mimicking brain microenvironments to understand and treat neurological disorders. APL Bioeng 2021; 5:020902. [PMID: 33869984 PMCID: PMC8034983 DOI: 10.1063/5.0043338] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2021] [Accepted: 03/22/2021] [Indexed: 12/16/2022] Open
Abstract
Neurological disorders including traumatic brain injury, stroke, primary and metastatic brain tumors, and neurodegenerative diseases affect millions of people worldwide. Disease progression is accompanied by changes in the brain microenvironment, but how these shifts in biochemical, biophysical, and cellular properties contribute to repair outcomes or continued degeneration is largely unknown. Tissue engineering approaches can be used to develop in vitro models to understand how the brain microenvironment contributes to pathophysiological processes linked to neurological disorders and may also offer constructs that promote healing and regeneration in vivo. In this Perspective, we summarize features of the brain microenvironment in normal and pathophysiological states and highlight strategies to mimic this environment to model disease, investigate neural stem cell biology, and promote regenerative healing. We discuss current limitations and resulting opportunities to develop tissue engineering tools that more faithfully recapitulate the aspects of the brain microenvironment for both in vitro and in vivo applications.
Collapse
Affiliation(s)
- Mai T. Ngo
- Department of Chemical and Biomolecular Engineering, University of Illinois at Urbana-Champaign, Urbana, Illinois 61801, USA
| | - Brendan A. C. Harley
- Author to whom correspondence should be addressed:. Tel.: (217) 244-7112. Fax: (217) 333-5052
| |
Collapse
|
11
|
Abstract
PURPOSE OF REVIEW Each year in the United States there are over 2.5 million visits to emergency departments for traumatic brain injury (TBI), 300,000 hospitalizations, and 50,000 deaths. TBI initiates a complex cascade of events which can lead to significant secondary brain damage. Great interest exists in directly measuring cerebral oxygen delivery and demand after TBI to prevent this secondary injury. Several invasive, catheter-based devices are now available which directly monitor the partial pressure of oxygen in brain tissue (PbtO2), yet significant equipoise exists regarding their clinical use in severe TBI. RECENT FINDINGS There are currently three ongoing multicenter randomized controlled trials studying the use of PbtO2 monitoring in severe TBI: BOOST-3, OXY-TC, and BONANZA. All three have similar inclusion/exclusion criteria, treatment protocols, and outcome measures. Despite mixed existing evidence, use of PbtO2 is already making its way into new TBI guidelines such as the recent Seattle International Brain Injury Consensus Conference. Analysis of high-fidelity data from multimodal monitoring, however, suggests that PbtO2 may only be one piece of the puzzle in severe TBI. SUMMARY While current evidence regarding the use of PbtO2 remains mixed, three ongoing clinical trials are expected to definitively answer the question of what role PbtO2 monitoring plays in severe TBI.
Collapse
Affiliation(s)
- Matthew R. Leach
- University of Pittsburgh, Department of Critical Care Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213
| | - Lori A. Shutter
- University of Pittsburgh, Department of Critical Care Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213
| |
Collapse
|
12
|
Takahashi CE, Virmani D, Chung DY, Ong C, Cervantes-Arslanian AM. Blunt and Penetrating Severe Traumatic Brain Injury. Neurol Clin 2021; 39:443-469. [PMID: 33896528 DOI: 10.1016/j.ncl.2021.02.009] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/09/2022]
Abstract
Severe traumatic brain injury is a common problem. Current practices focus on the importance of early resuscitation, transfer to high-volume centers, and provider expertise across multiple specialties. In the emergency department, patients should receive urgent intracranial imaging and consideration for tranexamic acid. Close observation in the intensive care unit environment helps identify problems, such as seizure, intracranial pressure crisis, and injury progression. In addition to traditional neurologic examination, patients benefit from use of intracranial monitors. Monitors gather physiologic data on intracranial and cerebral perfusion pressures to help guide therapy. Brain tissue oxygenation monitoring and cerebromicrodialysis show promise in studies.
Collapse
Affiliation(s)
- Courtney E Takahashi
- Department of Neurology, Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA.
| | - Deepti Virmani
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - David Y Chung
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA; Division of Neurocritical Care, Department of Neurology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA; Neurovascular Research Unit, Department of Radiology, Harvard Medical School, Massachusetts General Hospital, Boston, MA, USA
| | - Charlene Ong
- Department of Neurology, Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| | - Anna M Cervantes-Arslanian
- Boston University School of Medicine and Boston Medical Center, 72 East Concord Street, Collamore, C-3, Boston, MA 02118, USA
| |
Collapse
|
13
|
Individualized Brain Tissue Oxygen-Monitoring Probe Placement Helps to Guide Therapy and Optimizes Outcome in Neurocritical Care. Neurocrit Care 2020; 35:197-209. [PMID: 33326065 PMCID: PMC8285328 DOI: 10.1007/s12028-020-01171-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022]
Abstract
Background/Objective In order to monitor tissue oxygenation in patients with acute neurological disorders, probes for measurement of brain tissue oxygen tension (ptO2) are often placed non-specifically in a right frontal lobe location. To improve the value of ptO2 monitoring, placement of the probe into a specific area of interest is desirable. We present a technique using CT-guidance to place the ptO2 probe in a particular area of interest based on the individual patient’s pathology. Methods In this retrospective cohort study, we analyzed imaging and clinical data from all patients who underwent CT-guided ptO2 probe placement at our institution between October 2017 and April 2019. Primary endpoint was successful placement of the probe in a particular area of interest rated by two independent reviewers. Secondary outcomes were complications from probe insertion, clinical consequences from ptO2 measurements, clinical outcome according to the modified Rankin Scale (mRS) as well as development of ischemia on follow-up imaging. A historical control group was selected from patients who underwent conventional ptO2 probe placement between January 2010 and October 2017. Results Eleven patients had 16 CT-guided probes inserted. In 15 (93.75%) probes, both raters agreed on the correct placement in the area of interest. Each probe triggered on average 0.48 diagnostic or therapeutic adjustments per day. Only one infarction within the vascular territory of a probe was found on follow-up imaging. Eight out of eleven patients (72.73%) reached a good outcome (mRS ≤ 3). In comparison, conventionally placed probes triggered less diagnostic and therapeutic adjustment per day (p = 0.007). Outcome was worse in the control group (p = 0.024). Conclusion CT-guided probe insertion is a reliable and easy technique to place a ptO2 probe in a particular area of interest in patients with potentially reduced cerebral oxygen supply. By adjusting treatment aggressively according to this individualized monitoring data, clinical outcome may improve.
Collapse
|
14
|
The Importance of P btO 2 Probe Location for Data Interpretation in Patients with Intracerebral Hemorrhage. Neurocrit Care 2020; 34:804-813. [PMID: 32918157 PMCID: PMC8179893 DOI: 10.1007/s12028-020-01089-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/26/2020] [Indexed: 12/01/2022]
Abstract
Background/objective Monitoring of brain tissue oxygen tension (PbtO2) provides insight into brain pathophysiology after intracerebral hemorrhage (ICH). Integration of probe location is recommended to optimize data interpretation. So far, little is known about the importance of PbtO2 catheter location in ICH patients. Methods We prospectively included 40 ICH patients after hematoma evacuation (HE) who required PbtO2-monitoring. PbtO2-probe location was evaluated in all head computed tomography (CT) scans within the first 6 days after HE and defined as location in the healthy brain tissue or perilesional when the catheter tip was located within 1 cm of a focal lesion (hypodense or hyperdense). Generalized estimating equations were used to investigate levels of PbtO2 in relation to different probe locations. Results Patients were 60 [51–66] years old and had a median ICH-volume of 47 [29–60] mL. Neuromonitoring probes remained for a median of 6 [2–11] days. PbtO2-probes were located in healthy brain tissue in 18/40 (45%) patients and in perilesional brain tissue in 22/40 (55%) patients. In the acute phase after HE (0–72 h), PbtO2 levels were significantly lower (21 ± 12 mmHg vs. 29 ± 10 mmHg, p = 0.010) and brain tissue hypoxia (BTH) was more common in the perilesional area as compared to healthy brain tissue (46% vs. 19%, adjOR 4.0, 95% CI 1.54–10.58, p = 0.005). Episodes of BTH significantly decreased over time in patients with probes in perilesional location (p = 0.001) but remained stable in normal appearing area (p = 0.485). A significant association between BTH and poor functional outcome was only found when probes were located in the perilesional brain tissue (adjOR 6.6, 95% CI 1.3–33.8, p = 0.023). Conclusions In the acute phase, BTH was more common in the perilesional area compared to healthy brain tissue. The improvement of BTH in the perilesional area over time may be the result of targeted treatment interventions and tissue regeneration. Due to the localized measurement of invasive neuromonitoring devices, integration of probe location in the clinical management of ICH patients and in research protocols seems mandatory.
Collapse
|
15
|
Quiñones-Ossa GA, Durango-Espinosa YA, Padilla-Zambrano H, Ruiz J, Moscote-Salazar LR, Galwankar S, Gerber J, Hollandx R, Ghosh A, Pal R, Agrawal A. Current Status of Indications, Timing, Management, Complications, and Outcomes of Tracheostomy in Traumatic Brain Injury Patients. J Neurosci Rural Pract 2020; 11:222-229. [PMID: 32367975 PMCID: PMC7195963 DOI: 10.1055/s-0040-1709971] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
Tracheostomy is the commonest bedside surgical procedure performed on patients needing mechanical ventilation with traumatic brain injury (TBI). The researchers made an effort to organize a narrative review of the indications, timing, management, complications, and outcomes of tracheostomy in relation to neuronal and brain-injured patients following TBI. The study observations were collated from the published literature, namely original articles, book chapters, case series, randomized studies, systematic reviews, and review articles. Information sorting was restricted to tracheostomy and its association with TBI. Care was taken to review the correlation of tracheostomy with clinical correlates including indications, scheduling, interventions, prognosis, and complications of the patients suffering from mild, moderate and severe TBIs using Glasgow Coma Scale, Glasgow Outcome Scale, intraclass correlation coefficient, and other internationally acclaimed outcome scales. Tracheostomy is needed to overcome airway obstruction, prolonged respiratory failure and as indispensable component of mechanical ventilation due to diverse reasons in intensive care unit. Researchers are divided over early tracheostomy or late tracheostomy from days to weeks. The conventional classic surgical technique of tracheostomy has been superseded by percutaneous techniques by being less invasive with lesser complications, classified into early and late complications that may be life threatening. Additional studies have to be conducted to validate and streamline varied observations to frame evidence-based practice for successful weaning and decannulation. Tracheostomy is a safer option in critically ill TBI patients for which a universally accepted protocol for tracheostomy is needed that can help to optimize indications and outcomes.
Collapse
Affiliation(s)
| | - Y A Durango-Espinosa
- Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena de Indias, Colombia
| | - H Padilla-Zambrano
- Center for Biomedical Research (CIB), Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena de Indias, Colombia
| | - Jenny Ruiz
- Cartagena Neurotrauma Research Group Research Line, Faculty of Medicine, University of Cartagena, Cartagena de Indias, Colombia
| | - Luis Rafael Moscote-Salazar
- Center for Biomedical Research (CIB), Faculty of Medicine - University of Cartagena, Cartagena Colombia, CLaNi- Latin American Council of Neurocritical Care, Cartagena, Colombia
| | - S Galwankar
- Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Florida, United States
| | - J Gerber
- Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Florida, United States
| | - R Hollandx
- Department of Emergency Medicine, Sarasota Memorial Hospital, Florida State University, Florida, United States
| | - Amrita Ghosh
- Department of Biochemistry, Medical College, Kolkata, India
| | - R Pal
- Department of Community Medicine, MGM Medical College & LSK Hospital, Kishanganj, Bihar, India
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
| |
Collapse
|
16
|
Doron O, Or T, Battino L, Rosenthal G, Barnea O. Cerebral blood flow augmentation using a cardiac-gated intracranial pulsating balloon pump in a swine model of elevated ICP. J Neurosurg 2020; 132:1606-1615. [PMID: 30978692 DOI: 10.3171/2019.1.jns182864] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2018] [Accepted: 01/03/2019] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Augmenting brain perfusion or reducing intracranial pressure (ICP) dose is the end target of many therapies in the neuro-critical care unit. Many present therapies rely on aggressive systemic interventions that may lead to untoward effects. Previous studies have used a cardiac-gated intracranial balloon pump (ICBP) to model hydrocephalus or to flatten the ICP waveform. The authors sought to sought to optimize ICBP activation parameters to improve cerebral physiological parameters in a swine model of raised ICP. METHODS The authors developed a cardiac-gated ICBP in which the volume, timing, and duty cycle (time relative to a single cardiac cycle) of balloon inflation could be altered. They studied the ICBP in a swine model of elevated ICP attained by continuous intracranial fluid infusion with continuous monitoring of systemic and cerebral physiological parameters, and defined two specific protocols of ICBP activation. RESULTS Eleven swine were studied, 3 of which were studied to define the optimal timing, volume, and duty cycle of balloon inflation. Eight swine were studied with two defined protocols at baseline and with ICP gradually raised to a mean of 30.5 mm Hg. ICBP activation caused a consistent modification of the ICP waveform. Two ICBP activation protocols were used. Balloon activation protocol A led to a consistent elevation in cerebral blood flow (8%-25% above baseline, p < 0.00001). Protocol B resulted in a modest reduction of ICP over time (8%-11%, p < 0.0001) at all ICP levels. Neither protocol significantly affected systemic physiological parameters. CONCLUSIONS The preliminary results indicate that optimized protocols of ICBP activation may have beneficial effects on cerebral physiological parameters, with minimal effect on systemic parameters. Further studies are warranted to explore whether ICBP protocols may be of clinical benefit in patients with brain injuries with increased ICP.
Collapse
Affiliation(s)
- Omer Doron
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem; and
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Tal Or
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Limor Battino
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Guy Rosenthal
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem; and
| | - Ofer Barnea
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| |
Collapse
|
17
|
Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos. Neurocirugia (Astur) 2020; 31:24-36. [DOI: 10.1016/j.neucir.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 01/20/2023]
|
18
|
Cinotti R, Bouras M, Roquilly A, Asehnoune K. Management and weaning from mechanical ventilation in neurologic patients. ANNALS OF TRANSLATIONAL MEDICINE 2018; 6:381. [PMID: 30460255 DOI: 10.21037/atm.2018.08.16] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
In the early phase following severe brain injury (BI), mechanical ventilation (MV) is often needed to prevent airway from aspiration, control PaCO2 and PaO2 and avoid secondary brain insults. Although patients with BI are frequently hospitalized in the intensive care unit (ICU) without respiratory problems, they display longer durations of MV and a challenging weaning process compared to other ICU populations. Historically, the MV settings of BI patients associated high tidal volume with low or no positive end-expiratory pressure (PEEP), for neurological reasons. The extensive data about the beneficial effects of protective ventilation in patients without acute respiratory distress syndrome, have questioned the consequences of such management in BI patients. Recent studies suggest that protective ventilation is safe and could even bear significant impact on morbidity in these patients. The MV weaning process is also challenging, since these patients display a high rate of extubation failure. Recently, new clinical scales of successful extubation have been highlighted combining airway and neurologic operators. A minimal level of arousal should be achieved before extubation, but the Glasgow Coma Score has been inconsistently associated with successful extubation, probably owing to the challenging quantification in intubated patients. Early tracheostomy seems to bear positive effects on morbidity in BI patients. Nonetheless the level of evidence remains poor and no strong recommendations can be made on this topic. Overall, the respiratory bundle of care in BI patients could be readapted with the new data available in the literature. Even if they bear positive impact on morbidity in ICU, their consequences on neurological recovery have yet to be adequately assessed.
Collapse
Affiliation(s)
- Raphaël Cinotti
- Intensive Care Unit, Department of Anesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France.,Unité INSERM 942 "Biomarqueurs et pathologie cardiaque", Hôpital Lariboisière, Paris, France
| | - Marwan Bouras
- Intensive Care Unit, Department of Anesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France.,Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University Hospital of Nantes, Nantes, France
| | - Antoine Roquilly
- Intensive Care Unit, Department of Anesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France.,Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University Hospital of Nantes, Nantes, France
| | - Karim Asehnoune
- Intensive Care Unit, Department of Anesthesia and Critical Care, Hôtel Dieu, University Hospital of Nantes, Nantes, France.,Laboratoire UPRES EA 3826 "Thérapeutiques cliniques et expérimentales des infections", University Hospital of Nantes, Nantes, France
| |
Collapse
|
19
|
Zhao RT, Zhou J, Dong XL, Bi CW, Jiang RC, Dong JF, Tian Y, Yuan HJ, Zhang JN. Circular Ribonucleic Acid Expression Alteration in Exosomes from the Brain Extracellular Space after Traumatic Brain Injury in Mice. J Neurotrauma 2018; 35:2056-2066. [PMID: 29409384 DOI: 10.1089/neu.2017.5502] [Citation(s) in RCA: 49] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Affiliation(s)
- Rui-ting Zhao
- Department of Pharmacy, General Hospital, Tianjin Medical University, Tianjin, China
| | - Ju Zhou
- Department of Pharmacy, General Hospital, Tianjin Medical University, Tianjin, China
| | - Xin-long Dong
- Department of Neurosurgery, General Hospital, Tianjin Neurological Institute, Tianjin Medical University, Tianjin, China
| | - Chong-wen Bi
- Department of Pharmacy, General Hospital, Tianjin Medical University, Tianjin, China
| | - Rong-cai Jiang
- Department of Neurosurgery, General Hospital, Tianjin Neurological Institute, Tianjin Medical University, Tianjin, China
| | - Jing-fei Dong
- Bloodworks Research Institute, Bloodworks Northwest, Seattle, Washington
- Division of Hematology, Department of Medicine, University of Washington School of Medicine, Seattle, Washington
| | - Ye Tian
- Department of Neurosurgery, General Hospital, Tianjin Neurological Institute, Tianjin Medical University, Tianjin, China
| | - Heng-jie Yuan
- Department of Pharmacy, General Hospital, Tianjin Medical University, Tianjin, China
- Department of Neurosurgery, General Hospital, Tianjin Neurological Institute, Tianjin Medical University, Tianjin, China
| | - Jian-ning Zhang
- Department of Neurosurgery, General Hospital, Tianjin Neurological Institute, Tianjin Medical University, Tianjin, China
| |
Collapse
|
20
|
Cadena R, Shoykhet M, Ratcliff JJ. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2018; 27:82-88. [PMID: 28913634 DOI: 10.1007/s12028-017-0454-z] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this Emergency Neurological Life Support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.
Collapse
Affiliation(s)
- Rhonda Cadena
- Departments of Neurology, Neurosurgery, and Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA.
| | - Michael Shoykhet
- Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Jonathan J Ratcliff
- Departments of Emergency Medicine and Neurology, Emory University, Atlanta, GA, USA
| |
Collapse
|
21
|
Lubillo ST, Parrilla DM, Blanco J, Morera J, Dominguez J, Belmonte F, López P, Molina I, Ruiz C, Clemente FJ, Godoy DA. Prognostic value of changes in brain tissue oxygen pressure before and after decompressive craniectomy following severe traumatic brain injury. J Neurosurg 2018; 128:1538-1546. [PMID: 28665250 DOI: 10.3171/2017.1.jns161840] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022]
Abstract
OBJECTIVE In severe traumatic brain injury (TBI), the effects of decompressive craniectomy (DC) on brain tissue oxygen pressure (PbtO2) and outcome are unclear. The authors aimed to investigate whether changes in PbtO2 after DC could be used as an independent prognostic factor. METHODS The authors conducted a retrospective, observational study at 2 university hospital ICUs. The study included 42 patients who were admitted with isolated moderate or severe TBI and underwent intracranial pressure (ICP) and PbtO2 monitoring before and after DC. The indication for DC was an ICP higher than 25 mm Hg refractory to first-tier medical treatment. Patients who underwent primary DC for mass lesion evacuation were excluded. However, patients were included who had undergone previous surgery as long as it was not a craniectomy. ICP/PbtO2 monitoring probes were located in an apparently normal area of the most damaged hemisphere based on cranial CT scanning findings. PbtO2 values were routinely recorded hourly before and after DC, but for comparisons the authors used the first PbtO2 value on ICU admission and the number of hours with PbtO2 < 15 mm Hg before DC, as well as the mean PbtO2 every 6 hours during 24 hours pre- and post-DC. The end point of the study was the 6-month Glasgow Outcome Scale; a score of 4 or 5 was considered a favorable outcome, whereas a score of 1-3 was considered an unfavorable outcome. RESULTS Of the 42 patients included, 26 underwent unilateral DC and 16 bilateral DC. The median Glasgow Coma Scale score at the scene of the accident or at the initial hospital before the patient was transferred to one of the 2 ICUs was 7 (interquartile range [IQR] 4-14). The median time from admission to DC was 49 hours (IQR 7-301 hours). Before DC, the median ICP and PbtO2 at 6 hours were 35 mm Hg (IQR 28-51 mm Hg) and 11.4 mm Hg (IQR 3-26 mm Hg), respectively. In patients with favorable outcome, PbtO2 at ICU admission was higher and the percentage of time that pre-DC PbtO2 was < 15 mm Hg was lower (19 ± 4.5 mm Hg and 18.25% ± 21.9%, respectively; n = 28) than in those with unfavorable outcome (12.8 ± 5.2 mm Hg [p < 0.001] and 59.58% ± 38.8% [p < 0.001], respectively; n = 14). There were no significant differences in outcomes according to the mean PbtO2 values only during the last 12 hours before DC, the hours of refractory intracranial hypertension, the timing of DC from admission, or the presence/absence of previous surgery. In contrast, there were significant differences in PbtO2 values during the 12- to 24-hour period before DC. In most patients, PbtO2 increased during the 24 hours after DC but these changes were more pronounced in patients with favorable outcome than in those with unfavorable outcome (28.6 ± 8.5 mm Hg vs 17.2 ± 5.9 mm Hg, p < 0.0001; respectively). The areas under the curve for the mean PbtO2 values at 12 and 24 hours after DC were 0.878 (95% CI 0.75-1, p < 0.0001) and 0.865 (95% CI 0.73-1, p < 0.0001), respectively. CONCLUSIONS The authors' findings suggest that changes in PbtO2 before and after DC, measured with probes in healthy-appearing areas of the most damaged hemisphere, have independent prognostic value for the 6-month outcome in TBI patients.
Collapse
Affiliation(s)
| | | | | | - Jesús Morera
- 3Department of Neurosurgery, Hospital Universitario Dr. Negrín, Las Palmas, Spain; and
| | - Jaime Dominguez
- 4Department of Neurosurgery, Hospital Universitario N. S. de Candelaria, Tenerife
| | | | | | | | | | | | | |
Collapse
|
22
|
Respiratory Management in Patients with Severe Brain Injury. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:76. [PMID: 29558976 PMCID: PMC5861645 DOI: 10.1186/s13054-018-1994-0] [Citation(s) in RCA: 37] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Indexed: 01/23/2023]
Abstract
This article is one of ten reviews selected from the Annual Update in Intensive Care and Emergency Medicine 2018. Other selected articles can be found online at https://www.biomedcentral.com/collections/annualupdate2018 . Further information about the Annual Update in Intensive Care and Emergency Medicine is available from http://www.springer.com/series/8901 .
Collapse
|
23
|
Ghosh A, Highton D, Kolyva C, Tachtsidis I, Elwell CE, Smith M. Hyperoxia results in increased aerobic metabolism following acute brain injury. J Cereb Blood Flow Metab 2017; 37:2910-2920. [PMID: 27837190 PMCID: PMC5536254 DOI: 10.1177/0271678x16679171] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
Acute brain injury is associated with depressed aerobic metabolism. Below a critical mitochondrial pO2 cytochrome c oxidase, the terminal electron acceptor in the mitochondrial respiratory chain, fails to sustain oxidative phosphorylation. After acute brain injury, this ischaemic threshold might be shifted into apparently normal levels of tissue oxygenation. We investigated the oxygen dependency of aerobic metabolism in 16 acutely brain-injured patients using a 120-min normobaric hyperoxia challenge in the acute phase (24-72 h) post-injury and multimodal neuromonitoring, including transcranial Doppler ultrasound-measured cerebral blood flow velocity, cerebral microdialysis-derived lactate-pyruvate ratio (LPR), brain tissue pO2 (pbrO2), and tissue oxygenation index and cytochrome c oxidase oxidation state (oxCCO) measured using broadband spectroscopy. Increased inspired oxygen resulted in increased pbrO2 [ΔpbrO2 30.9 mmHg p < 0.001], reduced LPR [ΔLPR -3.07 p = 0.015], and increased cytochrome c oxidase (CCO) oxidation (Δ[oxCCO] + 0.32 µM p < 0.001) which persisted on return-to-baseline (Δ[oxCCO] + 0.22 µM, p < 0.01), accompanied by a 7.5% increase in estimated cerebral metabolic rate for oxygen ( p = 0.038). Our results are consistent with an improvement in cellular redox state, suggesting oxygen-limited metabolism above recognised ischaemic pbrO2 thresholds. Diffusion limitation or mitochondrial inhibition might explain these findings. Further investigation is warranted to establish optimal oxygenation to sustain aerobic metabolism after acute brain injury.
Collapse
Affiliation(s)
- Arnab Ghosh
- 1 Neurocritical Care, University College London Hospitals, National Hospital for Neurology & Neurosurgery, London, UK
| | - David Highton
- 1 Neurocritical Care, University College London Hospitals, National Hospital for Neurology & Neurosurgery, London, UK
| | - Christina Kolyva
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Ilias Tachtsidis
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Clare E Elwell
- 2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK
| | - Martin Smith
- 1 Neurocritical Care, University College London Hospitals, National Hospital for Neurology & Neurosurgery, London, UK.,2 Department of Medical Physics and Biomedical Engineering, University College London, London, UK.,3 University College London Hospitals National Institute for Health Research Biomedical Research Centre, London, UK
| |
Collapse
|
24
|
Stevens RD, Shoykhet M, Cadena R. Emergency Neurological Life Support: Intracranial Hypertension and Herniation. Neurocrit Care 2016; 23 Suppl 2:S76-82. [PMID: 26438459 DOI: 10.1007/s12028-015-0168-z] [Citation(s) in RCA: 70] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/22/2023]
Abstract
Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, a brain code mandates the organized implementation of a stepwise management algorithm. The goal of this emergency neurological life support protocol is to implement an evidence-based, standardized approach to the evaluation and management of patients with intracranial hypertension and/or herniation.
Collapse
Affiliation(s)
- Robert D Stevens
- Departments of Anesthesiology and Critical Care Medicine, Neurology, Neurosurgery, and Radiology, Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Michael Shoykhet
- Pediatric Critical Care Medicine, Department of Pediatrics, Washington University in St. Louis School of Medicine, St. Louis, MO, USA
| | - Rhonda Cadena
- Departments of Neurology, Neurosurgery, and Emergency Medicine, University of North Carolina School of Medicine, Chapel Hill, NC, USA
| |
Collapse
|
25
|
Hawryluk GWJ, Phan N, Ferguson AR, Morabito D, Derugin N, Stewart CL, Knudson MM, Manley G, Rosenthal G. Brain tissue oxygen tension and its response to physiological manipulations: influence of distance from injury site in a swine model of traumatic brain injury. J Neurosurg 2016; 125:1217-1228. [PMID: 26848909 DOI: 10.3171/2015.7.jns15809] [Citation(s) in RCA: 26] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECTIVE The optimal site for placement of tissue oxygen probes following traumatic brain injury (TBI) remains unresolved. The authors used a previously described swine model of focal TBI and studied brain tissue oxygen tension (PbtO2) at the sites of contusion, proximal and distal to contusion, and in the contralateral hemisphere to determine the effect of probe location on PbtO2 and to assess the effects of physiological interventions on PbtO2 at these different sites. METHODS A controlled cortical impact device was used to generate a focal lesion in the right frontal lobe in 12 anesthetized swine. PbtO2 was measured using Licox brain tissue oxygen probes placed at the site of contusion, in pericontusional tissue (proximal probe), in the right parietal region (distal probe), and in the contralateral hemisphere. PbtO2 was measured during normoxia, hyperoxia, hypoventilation, and hyperventilation. RESULTS Physiological interventions led to expected changes, including a large increase in partial pressure of oxygen in arterial blood with hyperoxia, increased intracranial pressure (ICP) with hypoventilation, and decreased ICP with hyperventilation. Importantly, PbtO2 decreased substantially with proximity to the focal injury (contusion and proximal probes), and this difference was maintained at different levels of fraction of inspired oxygen and partial pressure of carbon dioxide in arterial blood. In the distal and contralateral probes, hypoventilation and hyperventilation were associated with expected increased and decreased PbtO2 values, respectively. However, in the contusion and proximal probes, these effects were diminished, consistent with loss of cerebrovascular CO2 reactivity at and near the injury site. Similarly, hyperoxia led to the expected rise in PbtO2 only in the distal and contralateral probes, with little or no effect in the proximal and contusion probes, respectively. CONCLUSIONS PbtO2 measurements are strongly influenced by the distance from the site of focal injury. Physiological alterations, including hyperoxia, hyperventilation, and hypoventilation substantially affect PbtO2 values distal to the site of injury but have little effect in and around the site of contusion. Clinical interpretations of brain tissue oxygen measurements should take into account the spatial relation of probe position to the site of injury. The decision of where to place a brain tissue oxygen probe in TBI patients should also take these factors into consideration.
Collapse
Affiliation(s)
- Gregory W J Hawryluk
- Department of Neurological Surgery, University of Utah, Salt Lake City, Utah.,Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Nicolas Phan
- Brain and Spinal Injury Center, and.,Division of Neurological Surgery, Sunnybrook Health Sciences Centre, University of Toronto, Toronto, Ontario, Canada
| | - Adam R Ferguson
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Diane Morabito
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Nikita Derugin
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Campbell L Stewart
- Department of Dermatology, University of Pennsylvania, Philadelphia, Pennsylvania; and
| | - M Margaret Knudson
- Department of General Surgery, University of California, San Francisco, California
| | - Geoffrey Manley
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and
| | - Guy Rosenthal
- Department of Neurological Surgery.,Brain and Spinal Injury Center, and.,Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem, Israel
| |
Collapse
|
26
|
Abstract
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.
Collapse
|
27
|
Flynn LM, Rhodes J, Andrews PJ. Therapeutic Hypothermia Reduces Intracranial Pressure and Partial Brain Oxygen Tension in Patients with Severe Traumatic Brain Injury: Preliminary Data from the Eurotherm3235 Trial. Ther Hypothermia Temp Manag 2015; 5:143-51. [PMID: 26060880 PMCID: PMC4575517 DOI: 10.1089/ther.2015.0002] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant cause of disability and death and a huge economic burden throughout the world. Much of the morbidity associated with TBI is attributed to secondary brain injuries resulting in hypoxia and ischemia after the initial trauma. Intracranial hypertension and decreased partial brain oxygen tension (PbtO2) are targeted as potentially avoidable causes of morbidity. Therapeutic hypothermia (TH) may be an effective intervention to reduce intracranial pressure (ICP), but could also affect cerebral blood flow (CBF). This is a retrospective analysis of prospectively collected data from 17 patients admitted to the Western General Hospital, Edinburgh. Patients with an ICP >20 mmHg refractory to initial therapy were randomized to standard care or standard care and TH (intervention group) titrated between 32°C and 35°C to reduce ICP. ICP and PbtO2 were measured using the Licox system and core temperature was recorded through rectal thermometer. Data were analyzed at the hour before cooling, the first hour at target temperature, 2 consecutive hours at target temperature, and after 6 hours of hypothermia. There was a mean decrease in ICP of 4.3±1.6 mmHg (p<0.04) from 15.7 to 11.4 mmHg, from precooling to the first epoch of hypothermia in the intervention group (n=9) that was not seen in the control group (n=8). A decrease in ICP was maintained throughout all time periods. There was a mean decrease in PbtO2 of 7.8±3.1 mmHg (p<0.05) from 30.2 to 22.4 mmHg, from precooling to stable hypothermia, which was not seen in the control group. This research supports others in demonstrating a decrease in ICP with temperature, which could facilitate a reduction in the use of hyperosmolar agents or other stage II interventions. The decrease in PbtO2 is not below the suggested treatment threshold of 20 mmHg, but might indicate a decrease in CBF.
Collapse
Affiliation(s)
- Liam M.C. Flynn
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
| | - Jonathan Rhodes
- Department of Anesthesia and Critical Care, University of Edinburgh and NHS Lothian, Western General Hospital, Edinburgh, United Kingdom
| | - Peter J.D. Andrews
- Center for Clinical Brain Sciences, University of Edinburgh, Edinburgh, United Kindgom
| |
Collapse
|
28
|
De Santis V, Singer M. Tissue oxygen tension monitoring of organ perfusion: rationale, methodologies, and literature review. Br J Anaesth 2015. [PMID: 26198717 DOI: 10.1093/bja/aev162] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Tissue oxygen tension is the partial pressure of oxygen within the interstitial space of an organ bed. As it represents the balance between local oxygen delivery and consumption at any given time, it offers a ready monitoring capability to assess the adequacy of tissue perfusion relative to local demands. This review covers the various methodologies used to measure tissue oxygen tension, describes the underlying physiological and pathophysiological principles, and summarizes human and laboratory data published to date.
Collapse
Affiliation(s)
- V De Santis
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
| | - M Singer
- Bloomsbury Institute of Intensive Care Medicine, Division of Medicine, University College London, Cruciform Building, Gower Street, London WC1E 6BT, UK
| |
Collapse
|
29
|
Accuracy of brain multimodal monitoring to detect cerebral hypoperfusion after traumatic brain injury*. Crit Care Med 2015; 43:445-52. [PMID: 25393700 DOI: 10.1097/ccm.0000000000000720] [Citation(s) in RCA: 57] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
OBJECTIVE To examine the accuracy of brain multimodal monitoring-consisting of intracranial pressure, brain tissue PO2, and cerebral microdialysis--in detecting cerebral hypoperfusion in patients with severe traumatic brain injury. DESIGN Prospective single-center study. PATIENTS Patients with severe traumatic brain injury. SETTING Medico-surgical ICU, university hospital. INTERVENTION Intracranial pressure, brain tissue PO2, and cerebral microdialysis monitoring (right frontal lobe, apparently normal tissue) combined with cerebral blood flow measurements using perfusion CT. MEASUREMENTS AND MAIN RESULTS Cerebral blood flow was measured using perfusion CT in tissue area around intracranial monitoring (regional cerebral blood flow) and in bilateral supra-ventricular brain areas (global cerebral blood flow) and was matched to cerebral physiologic variables. The accuracy of intracranial monitoring to predict cerebral hypoperfusion (defined as an oligemic regional cerebral blood flow < 35 mL/100 g/min) was examined using area under the receiver-operating characteristic curves. Thirty perfusion CT scans (median, 27 hr [interquartile range, 20-45] after traumatic brain injury) were performed on 27 patients (age, 39 yr [24-54 yr]; Glasgow Coma Scale, 7 [6-8]; 24/27 [89%] with diffuse injury). Regional cerebral blood flow correlated significantly with global cerebral blood flow (Pearson r = 0.70, p < 0.01). Compared with normal regional cerebral blood flow (n = 16), low regional cerebral blood flow (n = 14) measurements had a higher proportion of samples with intracranial pressure more than 20 mm Hg (13% vs 30%), brain tissue PO2 less than 20 mm Hg (9% vs 20%), cerebral microdialysis glucose less than 1 mmol/L (22% vs 57%), and lactate/pyruvate ratio more than 40 (4% vs 14%; all p < 0.05). Compared with intracranial pressure monitoring alone (area under the receiver-operating characteristic curve, 0.74 [95% CI, 0.61-0.87]), monitoring intracranial pressure + brain tissue PO2 (area under the receiver-operating characteristic curve, 0.84 [0.74-0.93]) or intracranial pressure + brain tissue PO2+ cerebral microdialysis (area under the receiver-operating characteristic curve, 0.88 [0.79-0.96]) was significantly more accurate in predicting low regional cerebral blood flow (both p < 0.05). CONCLUSION Brain multimodal monitoring-including intracranial pressure, brain tissue PO2, and cerebral microdialysis--is more accurate than intracranial pressure monitoring alone in detecting cerebral hypoperfusion at the bedside in patients with severe traumatic brain injury and predominantly diffuse injury.
Collapse
|
30
|
Bohman LE, Pisapia JM, Sanborn MR, Frangos S, Lin E, Kumar M, Park S, Kofke WA, Stiefel MF, LeRoux PD, Levine JM. Response of brain oxygen to therapy correlates with long-term outcome after subarachnoid hemorrhage. Neurocrit Care 2014; 19:320-8. [PMID: 23949477 DOI: 10.1007/s12028-013-9890-6] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
BACKGROUND Brain oxygen (PbtO2) monitoring can help guide care of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) patients. The relationship between PbtO2-directed therapy and long-term outcome is unclear. We hypothesized that responsiveness to PbtO2-directed interventions is associated with outcome. METHODS Seventy-six aSAH patients who underwent PbtO2 monitoring were included. Long-term outcome [Glasgow Outcome Score-Extended (GOS-E) and modified Rankin Scale (mRS)] was ascertained using the social security death database and structured telephone interviews. Univariate and multivariate regression were used to identify variables that correlated with outcome. RESULTS Data from 64 patients were analyzed (12 were lost to follow-up). There were 530 episodes of compromised PbtO2 (<20 mmHg) during a total of 7,174 h of monitor time treated with 1,052 interventions. Forty-two patients (66 %) survived to discharge. Median follow-up was 8.5 months (range 0.1-87). At most recent follow-up 35 (55 %) patients were alive, and 28 (44 %) had a favorable outcome (mRS ≤3). In multivariate ordinal regression analysis, only age and response to PbtO2-directed intervention correlated significantly with outcome. Increased age was associated with worse outcome (coeff. 0.8, 95 % CI 0.3-1.3, p = 0.003), and response to PbtO2-directed intervention was associated with improved outcome (coeff. -2.12, 95 % CI -4.0 to -0.26, p = 0.03). Patients with favorable outcomes had a 70 % mean rate of response to PbtO2-directed interventions whereas patients with poor outcomes had a 45 % response rate (p = 0.005). CONCLUSIONS Response to PbtO2-directed intervention is associated with improved long-term functional outcome in aSAH patients.
Collapse
Affiliation(s)
- Leif-Erik Bohman
- Department of Neurosurgery, Hospital of the University of Pennsylvania, 3 W Gates, 3400 Spruce Street, Philadelphia, PA, 19104, USA
| | | | | | | | | | | | | | | | | | | | | |
Collapse
|
31
|
Domínguez-Berrot AM, González-Vaquero M, Díaz-Domínguez FJ, Robla-Costales J. [Multimodal neuromonitoring in traumatic brain injury: contribution of PTiO2]. Med Intensiva 2014; 38:513-21. [PMID: 24793091 DOI: 10.1016/j.medin.2014.02.005] [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: 11/26/2013] [Revised: 02/01/2014] [Accepted: 02/19/2014] [Indexed: 11/26/2022]
Abstract
The main goal of exhaustively monitoring neurocritical patients is to avoid secondary injury. In the last few years we have witnessed an increase in brain monitoring tools, beyond the checking of intracranial and brain perfusion pressures. These widely used systems offer valuable but possibly insufficient information. Awareness and correction of brain hypoxia is a useful and interesting measure, not only for diagnostic purposes but also when deciding treatment, and to predict an outcome. In this context, it would be of great interest to use all the information gathered from brain oxygenation monitoring systems in conjunction with other available multimodal monitoring devices, in order to offer individualized treatment for each patient.
Collapse
|
32
|
De Georgia MA. Brain Tissue Oxygen Monitoring in Neurocritical Care. J Intensive Care Med 2014; 30:473-83. [PMID: 24710714 DOI: 10.1177/0885066614529254] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/14/2014] [Indexed: 11/15/2022]
Abstract
Brain injury results from ischemia, tissue hypoxia, and a cascade of secondary events. The cornerstone of neurocritical care management is optimization and maintenance of cerebral blood flow (CBF) and oxygen and substrate delivery to prevent or attenuate this secondary damage. New techniques for monitoring brain tissue oxygen tension (PtiO2) are now available. Brain PtiO2 reflects both oxygen delivery and consumption. Brain hypoxia (low brain PtiO2) has been associated with poor outcomes in patients with brain injury. Strategies to improve brain PtiO2 have focused mainly on increasing oxygen delivery either by increasing CBF or by increasing arterial oxygen content. The results of nonrandomized studies comparing brain PtiO2-guided therapy with intracranial pressure/cerebral perfusion pressure-guided therapy, while promising, have been mixed. More studies are needed including prospective, randomized controlled trials to assess the true value of this approach. The following is a review of the physiology of brain tissue oxygenation, the effect of brain hypoxia on outcome, strategies to increase oxygen delivery, and outcome studies of brain PtiO2-guided therapy in neurocritical care.
Collapse
Affiliation(s)
- Michael A De Georgia
- Case Western Reserve University School of Medicine, Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH, USA
| |
Collapse
|
33
|
Kirkman MA, Smith M. Intracranial pressure monitoring, cerebral perfusion pressure estimation, and ICP/CPP-guided therapy: a standard of care or optional extra after brain injury? Br J Anaesth 2013; 112:35-46. [PMID: 24293327 DOI: 10.1093/bja/aet418] [Citation(s) in RCA: 55] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023] Open
Abstract
Measurement of intracranial pressure (ICP) and mean arterial pressure (MAP) is used to derive cerebral perfusion pressure (CPP) and to guide targeted therapy of acute brain injury (ABI) during neurointensive care. Here we provide a narrative review of the evidence for ICP monitoring, CPP estimation, and ICP/CPP-guided therapy after ABI. Despite its widespread use, there is currently no class I evidence that ICP/CPP-guided therapy for any cerebral pathology improves outcomes; indeed some evidence suggests that it makes no difference, and some that it may worsen outcomes. Similarly, no class I evidence can currently advise the ideal CPP for any form of ABI. 'Optimal' CPP is likely patient-, time-, and pathology-specific. Further, CPP estimation requires correct referencing (at the level of the foramen of Monro as opposed to the level of the heart) for MAP measurement to avoid CPP over-estimation and adverse patient outcomes. Evidence is emerging for the role of other monitors of cerebral well-being that enable the clinician to employ an individualized multimodality monitoring approach in patients with ABI, and these are briefly reviewed. While acknowledging difficulties in conducting robust prospective randomized studies in this area, such high-quality evidence for the utility of ICP/CPP-directed therapy in ABI is urgently required. So, too, is the wider adoption of multimodality neuromonitoring to guide optimal management of ICP and CPP, and a greater understanding of the underlying pathophysiology of the different forms of ABI and what exactly the different monitoring tools used actually represent.
Collapse
Affiliation(s)
- M A Kirkman
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK
| | | |
Collapse
|
34
|
Cerebral extracellular lactate increase is predominantly nonischemic in patients with severe traumatic brain injury. J Cereb Blood Flow Metab 2013; 33:1815-22. [PMID: 23963367 PMCID: PMC3824185 DOI: 10.1038/jcbfm.2013.142] [Citation(s) in RCA: 70] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2013] [Revised: 07/09/2013] [Accepted: 07/11/2013] [Indexed: 12/16/2022]
Abstract
Growing evidence suggests that endogenous lactate is an important substrate for neurons. This study aimed to examine cerebral lactate metabolism and its relationship with brain perfusion in patients with severe traumatic brain injury (TBI). A prospective cohort of 24 patients with severe TBI monitored with cerebral microdialysis (CMD) and brain tissue oxygen tension (PbtO2) was studied. Brain lactate metabolism was assessed by quantification of elevated CMD lactate samples (>4 mmol/L); these were matched to CMD pyruvate and PbtO2 values and dichotomized as glycolytic (CMD pyruvate >119 μmol/L vs. low pyruvate) and hypoxic (PbtO2 <20 mm Hg vs. nonhypoxic). Using perfusion computed tomography (CT), brain perfusion was categorized as oligemic, normal, or hyperemic, and was compared with CMD and PbtO2 data. Samples with elevated CMD lactate were frequently observed (41±8%), and we found that brain lactate elevations were predominantly associated with glycolysis and normal PbtO2 (73±8%) rather than brain hypoxia (14±6%). Furthermore, glycolytic lactate was always associated with normal or hyperemic brain perfusion, whereas all episodes with hypoxic lactate were associated with diffuse oligemia. Our findings suggest predominant nonischemic cerebral extracellular lactate release after TBI and support the concept that lactate may be used as an energy substrate by the injured human brain.
Collapse
|
35
|
Le Roux PD, Oddo M. Parenchymal brain oxygen monitoring in the neurocritical care unit. Neurosurg Clin N Am 2013; 24:427-39. [PMID: 23809036 DOI: 10.1016/j.nec.2013.03.001] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
Patients admitted to the neurocritical care unit (NCCU) often have serious conditions that can be associated with high morbidity and mortality. Pharmacologic agents or neuroprotectants have disappointed in the clinical environment. Current NCCU management therefore is directed toward identification, prevention, and treatment of secondary cerebral insults that evolve over time and are known to aggravate outcome. This strategy is based on a variety of monitoring techniques including use of intraparenchymal monitors. This article reviews parenchymal brain oxygen monitors, including the available technologies, practical aspects of use, the physiologic rationale behind their use, and patient management based on brain oxygen.
Collapse
Affiliation(s)
- Peter D Le Roux
- The Brain and Spine Center, Lankenau Medical Center, 100 E. Lancaster Ave, Wynnewood, PA 19096, USA.
| | | |
Collapse
|
36
|
Abstract
Sustained intracranial hypertension and acute brain herniation are "brain codes," signifying catastrophic neurological events that require immediate recognition and treatment to prevent irreversible injury and death. As in cardiac arrest, evidence supports the organized implementation of a stepwise management algorithm. Because there are multiple etiologies and many treatments that can potentially reverse cerebral herniation, intracranial hypertension and herniation was chosen as an Emergency Neurological Life Support (ENLS) protocol.
Collapse
|
37
|
Oxymétrie cérébrale. MEDECINE INTENSIVE REANIMATION 2013. [DOI: 10.1007/s13546-012-0540-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/27/2022]
|
38
|
Ponce LL, Pillai S, Cruz J, Li X, Julia H, Gopinath S, Robertson CS. Position of probe determines prognostic information of brain tissue PO2 in severe traumatic brain injury. Neurosurgery 2012; 70:1492-502; discussion 1502-3. [PMID: 22289784 DOI: 10.1227/neu.0b013e31824ce933] [Citation(s) in RCA: 58] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND Monitoring brain tissue PO2 (PbtO2) is part of multimodality monitoring of patients with traumatic brain injury (TBI). However, PbtO2 measurement is a sampling of only a small area of tissue surrounding the sensor tip. OBJECTIVE To examine the effect of catheter location on the relationship between PbtO2 and neurological outcome. METHODS A total of 405 patients who had PbtO2 monitoring as part of standard management of severe traumatic brain injury were studied. The relationships between probe location and resulting PbtO2 and outcome were examined. RESULTS When the probe was located in normal brain, PbtO2 averaged 30.8 ± 18.2 compared with 25.6 ± 14.8 mm Hg when placed in abnormal brain (P < .001). Factors related to neurological outcome in the best-fit logistic regression model were age, PbtO2 probe position, postresuscitation motor Glasgow Coma Scale score, and PbtO2 trend pattern. Although average PbtO2 was significantly related to outcome in univariate analyses, it was not significant in the final logistic model. However, the interaction between PbtO2 and probe position was statistically significant. When the PbtO2 probe was placed in abnormal brain, the average PbtO2 was higher in those with a favorable outcome, 28.8 ± 12.0 mm Hg, compared with those with an unfavorable outcome, 19.5 ± 13.7 mm Hg (P = .01). PbtO2 and outcome were not related when the probe was placed in normal-appearing brain. CONCLUSION These results suggest that the location of the PbtO2 probe determines the PbtO2 values and the relationship of PbtO2 to neurological outcome.
Collapse
Affiliation(s)
- Lucido L Ponce
- Department of Neurosurgery, Baylor College of Medicine, Houston, Texas 77030, USA
| | | | | | | | | | | | | |
Collapse
|
39
|
Oddo M, Levine JM, Mackenzie L, Frangos S, Feihl F, Kasner SE, Katsnelson M, Pukenas B, Macmurtrie E, Maloney-Wilensky E, Kofke WA, LeRoux PD. Brain hypoxia is associated with short-term outcome after severe traumatic brain injury independently of intracranial hypertension and low cerebral perfusion pressure. Neurosurgery 2012; 69:1037-45; discussion 1045. [PMID: 21673608 DOI: 10.1227/neu.0b013e3182287ca7] [Citation(s) in RCA: 78] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Brain hypoxia (BH) can aggravate outcome after severe traumatic brain injury (TBI). Whether BH or reduced brain oxygen (Pbto(2)) is an independent outcome predictor or a marker of disease severity is not fully elucidated. OBJECTIVE To analyze the relationship between Pbto(2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) and to examine whether BH correlates with worse outcome independently of ICP and CPP. METHODS We studied 103 patients monitored with ICP and Pbto(2) for > 24 hours. Durations of BH (Pbto(2) < 15 mm Hg), ICP > 20 mm Hg, and CPP < 60 mm Hg were calculated with linear interpolation, and their associations with outcome within 30 days were analyzed. RESULTS Duration of BH was longer in patients with unfavorable (Glasgow Outcome Scale score, 1-3) than in those with favorable (Glasgow Outcome Scale, 4-5) outcome (8.3 ± 15.9 vs 1.7 ± 3.7 hours; P < .01). In patients with intracranial hypertension, those with BH had fewer favorable outcomes (46%) than those without (81%; P < .01); similarly, patients with low CPP and BH were less likely to have favorable outcome than those with low CPP but normal Pbto(2) (39% vs 83%; P < .01). After ICP, CPP, age, Glasgow Coma Scale score, Marshall computed tomography grade, and Acute Physiology and Chronic Health Evaluation II score were controlled for, BH was independently associated with poor prognosis (adjusted odds ratio for favorable outcome, 0.89 per hour of BH; 95% confidence interval, 0.79-0.99; P = .04). CONCLUSION Brain hypoxia is associated with poor short-term outcome after severe traumatic brain injury independently of elevated ICP, low CPP, and injury severity. Pbto(2) may be an important therapeutic target after severe traumatic brain injury.
Collapse
Affiliation(s)
- Mauro Oddo
- Department of Neurosurgery, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19107, USA
| | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
40
|
Abstract
The main purpose of neurointensive care is to fight against cerebral ischaemia. Ischaemia is the cell energy failure following inadequacy between supply of glucose and oxygen and demand. Ischemia monitoring starts with a global approach, especially with cerebral perfusion pressure (CPP) determined by mean arterial pressure and intracranial pressure (ICP). However, global monitoring is insufficient to detect "regional" ischaemia, leading to development of local monitoring such as brain oxygen partial pressure (PtiO(2)). PtiO(2) is measured on a volume of a few mm(3) from a probe implanted in the cerebral tissue. The normal value is classically included between 25 and 35 mmHg and critical ischemic threshold is 10 mmHg. Understanding what exactly is PtiO(2) is still a matter of debate. PtiO(2) is more an indicator of oxygen diffusion depending of oxygen arterial pressure (PaO(2)) and local cerebral blood flow (CBF). Increase PaO(2) to treat PtiO(2) would hide information about local CBF. PtiO(2) is useful for the detection of low local CBF even when ICP is low as in hypocapnia-induced vasoconstriction. PtiO(2)-guided management could lead to a continuous optimization of arterial oxygen transport for an optimal cerebral tissue oxygenation. Finally, PtiO(2) has probably a global prognostic value because studies showed that hypoxic values for a long period of time lead to an unfavourable neurologic outcome. In conclusion, PtiO(2) provides additional information for regional monitoring of cerebral ischaemia and deserves more intensive use to better understand it and probably improve neurointensive care management.
Collapse
|
41
|
Oddo M, Levine JM, Kumar M, Iglesias K, Frangos S, Maloney-Wilensky E, Le Roux PD. Anemia and brain oxygen after severe traumatic brain injury. Intensive Care Med 2012; 38:1497-504. [PMID: 22584800 DOI: 10.1007/s00134-012-2593-1] [Citation(s) in RCA: 77] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2011] [Accepted: 04/23/2012] [Indexed: 01/25/2023]
Abstract
PURPOSE To investigate the relationship between hemoglobin (Hgb) and brain tissue oxygen tension (PbtO(2)) after severe traumatic brain injury (TBI) and to examine its impact on outcome. METHODS This was a retrospective analysis of a prospective cohort of severe TBI patients whose PbtO(2) was monitored. The relationship between Hgb-categorized into four quartiles (≤9; 9-10; 10.1-11; >11 g/dl)-and PbtO(2) was analyzed using mixed-effects models. Anemia with compromised PbtO(2) was defined as episodes of Hgb ≤ 9 g/dl with simultaneous PbtO(2) < 20 mmHg. Outcome was assessed at 30 days using the Glasgow outcome score (GOS), dichotomized as favorable (GOS 4-5) vs. unfavorable (GOS 1-3). RESULTS We analyzed 474 simultaneous Hgb and PbtO(2) samples from 80 patients (mean age 44 ± 20 years, median GCS 4 (3-7)). Using Hgb > 11 g/dl as the reference level, and controlling for important physiologic covariates (CPP, PaO(2), PaCO(2)), Hgb ≤ 9 g/dl was the only Hgb level that was associated with lower PbtO(2) (coefficient -6.53 (95 % CI -9.13; -3.94), p < 0.001). Anemia with simultaneous PbtO(2) < 20 mmHg, but not anemia alone, increased the risk of unfavorable outcome (odds ratio 6.24 (95 % CI 1.61; 24.22), p = 0.008), controlling for age, GCS, Marshall CT grade, and APACHE II score. CONCLUSIONS In this cohort of severe TBI patients whose PbtO(2) was monitored, a Hgb level no greater than 9 g/dl was associated with compromised PbtO(2). Anemia with simultaneous compromised PbtO(2), but not anemia alone, was a risk factor for unfavorable outcome, irrespective of injury severity.
Collapse
Affiliation(s)
- Mauro Oddo
- Department of Neurosurgery, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA 19104, USA.
| | | | | | | | | | | | | |
Collapse
|
42
|
Keddie S, Rohman L. Reviewing the reliability, effectiveness and applications of Licox in traumatic brain injury. Nurs Crit Care 2012; 17:204-12. [PMID: 22698163 DOI: 10.1111/j.1478-5153.2012.00499.x] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
AIMS AND OBJECTIVES To review the pathophysiology, accuracy, effectiveness and use of Licox for brain tissue oxygen monitoring in traumatic brain injury (TBI). BACKGROUND The Licox monitoring system allows continuous monitoring of partial pressure of brain tissue oxygen (PbO(2)), brain tissue temperature and intracranial pressure (ICP). The application and effectiveness of the use of Licox in TBI is not clearly explored within the literature. INCLUSION CRITERIA A date limit of 1995-2009, English language, all animal and human studies and the following terms were searched: Licox, brain tissue oxygenation, cerebral oxygenation and TBI. MEDLINE database was the primary data source. EXCLUSION CRITERIA All paediatric papers were excluded from the search. Studies not related to pathophysiology and management of TBI and brain tissue oximetry in adults were excluded. Data relevant to the subject under consideration were extracted by three independent clinicians to form a narrative report. Studies were critically evaluated using the NHS Public Health Resource Unit's checklist for each study analysed. CONCLUSIONS Licox offers new insights into cerebral pathology and physiology. The continuous bedside monitoring provides real-time data that can be used to improve patient management and prognosis in specialist units by trained and experienced staff. More research is required to understand the limitations of this technology and why it is not in widespread use. RELEVENCE TO CLINICAL PRACTICE: A clinical tool that could be utilized more often in the right setting to improve care to patients suffering from TBI by disseminating more information on this unique tool.
Collapse
Affiliation(s)
- Stephen Keddie
- Wansbeck General Hospital, Education Centre, Woodhorn Lane, Ashington, Northumberland, UK
| | | |
Collapse
|
43
|
Stover JF. Contemporary view on neuromonitoring following severe traumatic brain injury. World J Crit Care Med 2012; 1:15-22. [PMID: 24701397 PMCID: PMC3956064 DOI: 10.5492/wjccm.v1.i1.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/27/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Evolving brain damage following traumatic brain injury (TBI) is strongly influenced by complex pathophysiologic cascades including local as well as systemic influences. To successfully prevent secondary progression of the primary damage we must actively search and identify secondary insults e.g. hypoxia, hypotension, uncontrolled hyperventilation, anemia, and hypoglycemia, which are known to aggravate existing brain damage. For this, we must rely on specific cerebral monitoring. Only then can we unmask changes which otherwise would remain hidden, and prevent adequate intensive care treatment. Apart from intracranial pressure (ICP) and calculated cerebral perfusion pressure (CPP), extended neuromonitoring (SjvO2, ptiO2, microdialysis, transcranial Doppler sonography, electrocorticography) also allows us to define individual pathologic ICP and CPP levels. This, in turn, will support our therapeutic decision-making and also allow a more individualized and flexible treatment concept for each patient. For this, however, we need to learn to integrate several dimensions with their own possible treatment options into a complete picture. The present review summarizes the current understanding of extended neuromonitoring to guide therapeutic interventions with the aim of improving intensive care treatment following severe TBI, which is the basis for ameliorated outcome.
Collapse
Affiliation(s)
- John F Stover
- John F Stover, Surgical Intensive Care Medicine, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
| |
Collapse
|
44
|
Kurland D, Hong C, Aarabi B, Gerzanich V, Simard JM. Hemorrhagic progression of a contusion after traumatic brain injury: a review. J Neurotrauma 2011; 29:19-31. [PMID: 21988198 DOI: 10.1089/neu.2011.2122] [Citation(s) in RCA: 211] [Impact Index Per Article: 16.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
The magnitude of damage to cerebral tissues following head trauma is determined by the primary injury, caused by the kinetic energy delivered at the time of impact, plus numerous secondary injury responses that almost inevitably worsen the primary injury. When head trauma results in a cerebral contusion, the hemorrhagic lesion often progresses during the first several hours after impact, either expanding or developing new, non-contiguous hemorrhagic lesions, a phenomenon termed hemorrhagic progression of a contusion (HPC). Because a hemorrhagic contusion marks tissues with essentially total unrecoverable loss of function, and because blood is one of the most toxic substances to which the brain can be exposed, HPC is one of the most severe types of secondary injury encountered following traumatic brain injury (TBI). Historically, HPC has been attributed to continued bleeding of microvessels fractured at the time of primary injury. This concept has given rise to the notion that continued bleeding might be due to overt or latent coagulopathy, prompting attempts to normalize coagulation with agents such as recombinant factor VIIa. Recently, a novel mechanism was postulated to account for HPC that involves delayed, progressive microvascular failure initiated by the impact. Here we review the topic of HPC, we examine data relevant to the concept of a coagulopathy, and we detail emerging data elucidating the mechanism of progressive microvascular failure that predisposes to HPC after head trauma.
Collapse
Affiliation(s)
- David Kurland
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, Maryland 21201-1595, USA
| | | | | | | | | |
Collapse
|
45
|
Kitamura G, Kido D, Wycliffe N, Jacobson JP, Oyoyo U, Ashwal S. Hypoxic-ischemic injury: utility of susceptibility-weighted imaging. Pediatr Neurol 2011; 45:220-4. [PMID: 21907881 DOI: 10.1016/j.pediatrneurol.2011.06.009] [Citation(s) in RCA: 25] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/22/2011] [Revised: 04/20/2011] [Accepted: 06/23/2011] [Indexed: 11/16/2022]
Abstract
Magnetic resonance imaging is increasingly used to assess neonatal hypoxic-ischemic injury, and several scoring systems were developed to predict neurologic outcomes in these patients. We examined the magnetic resonance imaging studies of 33 neonates/infants who manifested acute perinatal hypoxic-ischemic injuries. Using a seven-point susceptibility-weighted imaging categorical grading scale, each patient received a "prominence of vein" score, which was dichotomized into a "normal" or "abnormal" group. Six-month outcomes were assessed using the Pediatric Cerebral Performance Category Scale. We then determined whether "prominence of vein" scores correlated with neurologic outcomes in patients with hypoxic-ischemic injuries, and compared these results with the Barkovich magnetic resonance imaging scoring system. Patients with "normal" "prominence of vein" scores demonstrated better outcomes (mean Pediatric Cerebral Performance Category Scale value = 2) than patients with "abnormal" "prominence of vein" scores (mean Pediatric Cerebral Performance Category Scale value = 4). The dichotomized "prominence of vein" groups demonstrated correlations with the Barkovich magnetic resonance imaging scores of the proton density-weighted basal ganglia, watershed, and combined basal ganglia/watershed regions. The susceptibility-weighted imaging categorical grading scale may aid in predicting neurologic outcomes after hypoxic-ischemic injuries.
Collapse
Affiliation(s)
- Gene Kitamura
- Department of Radiology, Loma Linda University School of Medicine, Loma Linda, California 92350, USA
| | | | | | | | | | | |
Collapse
|
46
|
Smith CM, Adelson PD, Chang YF, Brown SD, Kochanek PM, Clark RSB, Bayır H, Hinchberger J, Bell MJ. Brain-systemic temperature gradient is temperature-dependent in children with severe traumatic brain injury. Pediatr Crit Care Med 2011; 12:449-54. [PMID: 20711083 PMCID: PMC5055080 DOI: 10.1097/pcc.0b013e3181f390dd] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
OBJECTIVES To understand the gradient between rectal and brain temperature in children after severe traumatic brain injury. We hypothesized that the rectal temperature and brain temperature gradient will be influenced by the child's body surface area and that this relationship will persist over physiologic temperature ranges. DESIGN Retrospective review of a prospectively collected pediatric neurotrauma registry. SETTING Academic, university-based pediatric neurotrauma program. PATIENTS Consecutive children (n = 40) with severe traumatic brain injury (Glasgow coma scale of <8) who underwent brain temperature monitoring (July 2003 to December 2008) were studied after informed consent was obtained. A subset of children (n = 24) were concurrently enrolled in a randomized, controlled clinical trial of early-moderate hypothermia for neuroprotection. INTERVENTIONS Data extraction of multiple clinical variables, including demographic data, body surface area, and rectal and brain temperature at recorded at hourly intervals. MEASUREMENTS AND MAIN RESULTS Paired brain and rectal temperature measurements (in degrees Celsius, n = 4369) were collected hourly and compared by using Pearson correlations. Patients were stratified according to body surface area (<1.0 m, 1.0-1.99 m, 2.0-2.99 m, and >3.0 m) and based on brain temperature (≤34.0, 34.1-36.0; 36.1-38, ≥38.1). Body surface area and brain temperature were compared between groups by using Pearson correlations with correction for repeated measures. Mean brain temperature-rectal temperature difference was calculated for stratified brain temperature ranges. Overall, brain and rectal temperatures were highly correlated (r = .86, p < .001). During brain hyperthermia, brain temperature-rectal temperature was similar to that reported in previous studies with brain temperature higher than rectal temperature (1.75 ± 0.4; r = .54). Surprisingly, this relationship was reversed during brain hypothermia (brain temperature-rectal temperature = -1.87 ± 0.8; r = .37), indicating a reversal of the brain-systemic temperature gradient. When stratified for body surface area, the correlation between rectal temperature and brain temperature remained strong (r = .78, 0.91, 0.79 and 0.95, respectively, p < .001). However, the correlation between brain temperature and rectal temperature was substantially decreased when stratified for brain temperature (r = .37, 0.58, 0.48, 0.54, p < .001). In particular, during moderate brain hypothermia (brain temperature ≤34), the correlation between brain temperature and rectal temperature was weakest, indicating the greatest variability during this condition which is often targeted for therapeutic trials. CONCLUSIONS Brain temperature and rectal temperature are generally well-correlated in children with traumatic brain injury. This relationship is different at the extremes of the physiologic temperature range, with the temperature gradient reversed during brain hypothermia and hyperthermia. Given that studies showing neuroprotection from hypothermia in animal models of brain injury generally target brain temperature, our data suggest the possibility that, if brain temperature were the therapeutic target in clinical trials, this would result in somewhat higher systemic temperature and potentially fewer side effects. This relationship may be exploited in future clinical trials to maintain brain hypothermia (for neurologic protection) at slightly higher systemic temperatures (and potentially fewer systemic side effects).
Collapse
Affiliation(s)
- Craig M. Smith
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - P. David Adelson
- Department of Neurosurgery, Phoenix Children’s Hospital, Phoenix, AZ
| | - Yue-Fang Chang
- Department of Neurological Surgery, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - S. Danielle Brown
- Department of Neurosurgery, Phoenix Children’s Hospital, Phoenix, AZ
| | - Patrick M. Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Robert S. B. Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Hülya Bayır
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Jessica Hinchberger
- Department of Nursing, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| | - Michael J. Bell
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA,Department of Neurological Surgery, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA,Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine and Children’s Hospital of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
47
|
Invasive and noninvasive assessment of cerebral oxygenation in patients with severe traumatic brain injury. Intensive Care Med 2010; 36:1309-17. [PMID: 20502869 DOI: 10.1007/s00134-010-1920-7] [Citation(s) in RCA: 66] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2009] [Accepted: 03/25/2010] [Indexed: 10/19/2022]
Abstract
PURPOSE The aim of this study is to investigate the relationship between invasive brain tissue oxygen pressure (PbrO(2)) and noninvasive regional transcranial oxygen saturation (rSO(2)) in 22 stable patients with severe traumatic brain injury (TBI) during a 16 h period. METHODS This was a prospective, observational study carried out in the Neurocritical Care Unit of a level 1 trauma center in a teaching hospital. A total of 41,809 paired records for neuromonitoring variables were analyzed and compared. RESULTS A direct and independent correlation between rSO(2) and PbrO(2) was confirmed through adjusted [beta coefficient and (95% confidence interval, CI) = 0.36 (0.35-0.37)] and logistic [PbrO(2) >or=15 mmHg, as a dependent variable; adjusted odds ratio (AOR) and (95% CI) = 1.11 (1.10-1.12)] regression analyses. A receiver-operating characteristic (ROC) curve demonstrated that rSO(2) had low accuracy for detecting moderate (PbrO(2) <or=15 mmHg) intracerebral hypoxia [area under curve (AUC) = 0.62], with the likelihood ratio for a positive test (LR+) = 1.2 for an optimal cutoff of rSO(2) <or=70%. In contrast, the ROC analysis showed that rSO(2) was moderately accurate for detecting severe (PbrO(2) <or=12 mmHg) intracerebral hypoxemia (AUC = 0.82; LR+ = 5.3) for an optimal cutoff of rSO(2) <or=60%. CONCLUSIONS In patients with severe TBI, PbrO(2) and rSO(2) were directly and significantly related. Severe intracerebral hypoxia was better detected by rSO(2) than was moderate intracerebral hypoxia. However, the diagnostic accuracy of rSO(2) was limited, and this measure should not be considered a substitute for routine PbrO(2) monitoring.
Collapse
|
48
|
Stein SC, Georgoff P, Meghan S, Mirza KL, El Falaky OM. Relationship of aggressive monitoring and treatment to improved outcomes in severe traumatic brain injury. J Neurosurg 2010; 112:1105-12. [PMID: 19747054 DOI: 10.3171/2009.8.jns09738] [Citation(s) in RCA: 103] [Impact Index Per Article: 7.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
OBJECT Despite being common practice for decades and being recommended by national guidelines, aggressive monitoring and treatment of patients with severe traumatic brain injury (TBI) have not been supported by convincing evidence. METHODS The authors reviewed trials and case series reported after 1970 in which patients were treated for severe closed TBI, and mortality rates and favorable outcomes at 6 months after injury were analyzed. The patient groups were divided into those with and without intracranial pressure (ICP) monitoring and intensive therapy, and the authors performed a meta-analysis to assess the effects of treatment intensity on outcome. RESULTS Although the mortality rate fell during the years reviewed, it was consistently approximately 12% lower among patients in the intense treatment group (p < 0.001). Favorable outcomes did not change significantly over time, and were 6% higher among the aggressively treated patients (p = 0.0105). CONCLUSIONS Aggressive ICP monitoring and treatment of patients with severe TBI is associated with a statistically significant improvement in outcome. This improvement occurs independently of temporal effects.
Collapse
Affiliation(s)
- Sherman C Stein
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania 19104, USA.
| | | | | | | | | |
Collapse
|
49
|
Kumaria A, Tolias CM. Normobaric hyperoxia therapy for traumatic brain injury and stroke: a review. Br J Neurosurg 2010; 23:576-84. [PMID: 19922270 DOI: 10.3109/02688690903050352] [Citation(s) in RCA: 46] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
Traumatic brain injury (TBI) and acute ischaemic stroke are major causes of mortality and morbidity and there is an urgent demand for new neuroprotective strategies following the translational failure of neuroprotective drug trials. Oxygen therapy--especially normobaric, may offer a simple and effective therapeutic strategy which we review in this paper. Firstly we review mechanisms underlying the therapeutic effects of hyperoxia (both normobaric and hyperbaric) including mitochondrial rescue, stabilisation of intracranial pressure, attenuation of cortical spreading depression and inducing favourable endothelial-leukocyte interactions, all effects of which are postulated to decrease secondary injury. Next we survey studies using hyperbaric oxygen therapy for TBI and stroke, which formed the basis for early studies on normobaric hyperoxia. Thirdly, we present clinical studies of the efficacy of normobaric hyperoxia on TBI and stroke, emphasising their safety, efficacy and practicality. Finally we consider safety concerns and side effects, particularly pulmonary pathology, respiratory failure and theoretical risks in paediatric patients. A neuroprotective role of normobaric hyperoxia is extremely promising and further studies are warranted.
Collapse
Affiliation(s)
- Ashwin Kumaria
- Department of Neurosurgery, King's College Hospital, London, UK.
| | | |
Collapse
|
50
|
Anderson J, Sandhir R, Hamilton ES, Berman NEJ. Impaired expression of neuroprotective molecules in the HIF-1alpha pathway following traumatic brain injury in aged mice. J Neurotrauma 2009; 26:1557-66. [PMID: 19203226 DOI: 10.1089/neu.2008.0765] [Citation(s) in RCA: 50] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Abstract
Elderly traumatic brain injury (TBI) patients have higher rates of mortality and worse functional outcome than non-elderly TBI patients. The mechanisms involved in poor outcomes in the elderly are not well understood. Hypoxia-inducible factor-1 alpha (HIF-1alpha) is a basic helix-loop-helix transcription factor that modulates expression of key genes involved in neuroprotection. In this study, we studied the expression of HIF-1alpha and its target survival genes, heme oxygenase-1 (HO-1), vascular endothelial growth factor (VEGF), and erythropoietin (EPO) in the brains of adult versus aged mice following controlled cortical impact (CCI) injury. Adult (5-6 months) and aged (23-24 months) C57Bl/6 mice were injured using a CCI device. At 72 h post-injury, mice were sacrificed and the injured cortex was used for mRNA and protein analysis using real-time reverse transcription--polymerase chain reaction (RT-PCR) and Western blotting protocols. Following injury, HIF-1alpha, HO-1, and VEGF showed upregulation in both the young and aged mice, but in the aged animals the increase in HIF-1alpha and VEGF in response to injury was much lower than in the adult injured animals. EPO was upregulated in the adult injured brain, but not in the aged injured brain. These results support the hypothesis that reduced expression of genes in the HIF-1alpha neuroprotective pathway in aging may contribute to poor prognosis in the elderly following TBI.
Collapse
Affiliation(s)
- Joshua Anderson
- Steve Palermo Nerve Regeneration Laboratory, University of Kansas Medical Center, Kansas City, Kansas, USA
| | | | | | | |
Collapse
|