1
|
Chen KW, Chen YR, Yang LY, Cheng YW, Chou SC, Chen YH, Chen YT, Hsieh ST, Kuo MF, Wang KC. Microcirculatory Impairment and Cerebral Injury in Hydrocephalus and the Effects of Cerebrospinal Fluid Diversion. Neurosurgery 2024; 95:469-479. [PMID: 38511941 DOI: 10.1227/neu.0000000000002908] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 01/22/2024] [Indexed: 03/22/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Hydrocephalus is characterized by progressive enlargement of cerebral ventricles, resulting in impaired microvasculature and cerebral hypoperfusion. This study aimed to demonstrate the microvascular changes in hydrocephalic rats and the effects of cerebrospinal fluid (CSF) release on cerebral blood flow (CBF). METHODS On postnatal day 21 (P21), male Wistar rats were intracisternally injected with either a kaolin suspension or saline. On P47, Evan's ratio (ER) was measured using MRI. On P49, the arteriolar diameter and vascular density of the pia were quantified using a capillary video microscope. The CBF was measured using laser Doppler flowmetry. The expressions of NeuN and glial fibrillary acidic protein determined by immunochemical staining were correlated with the ER. The CBF and rotarod test performance were recorded before and after CSF release. The expressions of 4-hydroxynonenal (4-HNE) and c-caspase-3 were studied on P56. RESULTS Ventriculomegaly was induced to varying degrees, resulting in the stretching and abnormal narrowing of pial arterioles, which regressed with increasing ER. Quantitative analysis revealed significant decreases in the arteriolar diameter and vascular density in the hydrocephalic group compared with those in the control group. In addition, the CBF in the hydrocephalic group decreased to 30%-50% of that in the control group. In hydrocephalus, the neurons appear distorted, and the expression of 4-HNE and reactive astrogliosis increase in the cortex. After CSF was released, improvements in the CBF and rotarod test performance were inversely associated with the ER. In addition, the levels of 4-HNE and c-caspase-3 were further elevated. CONCLUSION Rapid ventricular dilatation is associated with severe microvascular distortion, vascular regression, cortical hypoperfusion, and cellular changes that impair the recovery of CBF and motor function after CSF release. Moreover, CSF release may induce reperfusion injury. This pathophysiology should be taken into account when treating hydrocephalus.
Collapse
Affiliation(s)
- Kuo-Wei Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei , Taiwan
- Master Degree of Public Health, College of Public Health, National Taiwan University, Taipei , Taiwan
| | - Yong-Ren Chen
- Non-invasive Cancer Therapy Research Institute, Taipei , Taiwan
| | - Ling-Yu Yang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
| | - Ya-Wen Cheng
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
| | - Sheng-Che Chou
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei , Taiwan
- Department of Traumatology, National Taiwan University Hospital, National Taiwan University, College of Medicine, Taipei , Taiwan
| | - Yi-Hsing Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
- Graduate Institute of Clinical Medicine, National Taiwan University College of Medicine, Taipei , Taiwan
| | - Yi-Tzu Chen
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei , Taiwan
- Department of Anatomy and Cell Biology, National Taiwan University College of Medicine, Taipei , Taiwan
| | - Meng-Fai Kuo
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
| | - Kuo-Chuan Wang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital and National Taiwan University College of Medicine, Taipei , Taiwan
| |
Collapse
|
2
|
Battaglini D, Bogossian EG, Anania P, Premraj L, Cho SM, Taccone FS, Sekhon M, Robba C. Monitoring of Brain Tissue Oxygen Tension in Cardiac Arrest: a Translational Systematic Review from Experimental to Clinical Evidence. Neurocrit Care 2024; 40:349-363. [PMID: 37081276 DOI: 10.1007/s12028-023-01721-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 03/24/2023] [Indexed: 04/22/2023]
Abstract
BACKGROUND Cardiac arrest (CA) is a sudden event that is often characterized by hypoxic-ischemic brain injury (HIBI), leading to significant mortality and long-term disability. Brain tissue oxygenation (PbtO2) is an invasive tool for monitoring brain oxygen tension, but it is not routinely used in patients with CA because of the invasiveness and the absence of high-quality data on its effect on outcome. We conducted a systematic review of experimental and clinical evidence to understand the role of PbtO2 in monitoring brain oxygenation in HIBI after CA and the effect of targeted PbtO2 therapy on outcomes. METHODS The search was conducted using four search engines (PubMed, Scopus, Embase, and Cochrane), using the Boolean operator to combine mesh terms such as PbtO2, CA, and HIBI. RESULTS Among 1,077 records, 22 studies were included (16 experimental studies and six clinical studies). In experimental studies, PbtO2 was mainly adopted to assess the impact of gas exchanges, drugs, or systemic maneuvers on brain oxygenation. In human studies, PbtO2 was rarely used to monitor the brain oxygen tension in patients with CA and HIBI. PbtO2 values had no clear association with patients' outcomes, but in the experimental studies, brain tissue hypoxia was associated with increased inflammation and neuronal damage. CONCLUSIONS Further studies are needed to validate the effect and the threshold of PbtO2 associated with outcome in patients with CA, as well as to understand the physiological mechanisms influencing PbtO2 induced by gas exchanges, drug administration, and changes in body positioning after CA.
Collapse
Affiliation(s)
- Denise Battaglini
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Pasquale Anania
- Department of Neurosurgery, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy.
| | - Lavienraj Premraj
- Griffith University School of Medicine, Gold Coast, QLD, Australia
- Critical Care Research Group, The Prince Charles Hospital, Brisbane, QLD, Australia
| | - Sung-Min Cho
- Departments of Neurology, Surgery, and Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hospital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, University of British Columbia, Vancouver, BC, Canada
| | - Chiara Robba
- Anesthesiology and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neurosciences, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| |
Collapse
|
3
|
Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
Collapse
Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| |
Collapse
|
4
|
Godoy DA, Brasil S, Iaccarino C, Paiva W, Rubiano AM. The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management. Crit Care 2023; 27:137. [PMID: 37038236 PMCID: PMC10088257 DOI: 10.1186/s13054-023-04427-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023] Open
Abstract
For decades, one of the main targets in the management of severe acute brain injury (ABI) has been intracranial hypertension (IH) control. However, the determination of IH has suffered variations in its thresholds over time without clear evidence for it. Meanwhile, progress in the understanding of intracranial content (brain, blood and cerebrospinal fluid) dynamics and recent development in monitoring techniques suggest that targeting intracranial compliance (ICC) could be a more reliable approach rather than guiding actions by predetermined intracranial pressure values. It is known that ICC impairment forecasts IH, as intracranial volume may rapidly increase inside the skull, a closed bony box with derisory expansibility. Therefore, an intracranial compartmental syndrome (ICCS) can occur with deleterious brain effects, precipitating a reduction in brain perfusion, thereby inducing brain ischemia. The present perspective review aims to discuss the ICCS concept and suggest an integrative model for the combination of modern invasive and noninvasive techniques for IH and ICC assessment. The theory and logic suggest that the combination of multiple ancillary methods may enhance ICC impairment prediction, pointing proactive actions and improving patient outcomes.
Collapse
Affiliation(s)
| | - Sérgio Brasil
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil.
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University Modena and Reggio Emilia, Modena, Italy
- Department of Neurosurgery, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery, AUSLRE IRCCS, Reggio Emilia, Italy
| | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil
| | - Andres M Rubiano
- Universidad El Bosque. Bogotá, Bogotá, Colombia
- MEDITECH Foundation, Cali, Colombia
| |
Collapse
|
5
|
Nelskylä A, Humaloja J, Litonius E, Pekkarinen P, Babini G, Mäki-Aho TP, Heinonen JA, Skrifvars MB. The use of 100% compared to 50% oxygen during ineffective experimental cardiopulmonary resuscitation improves brain oxygenation. Resuscitation 2023; 182:109656. [PMID: 36470536 DOI: 10.1016/j.resuscitation.2022.11.022] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/12/2022] [Revised: 11/17/2022] [Accepted: 11/26/2022] [Indexed: 12/07/2022]
Abstract
INTRODUCTION Perfusion pressure and chest compression quality are generally considered key determinants of brain oxygenation during cardiopulmonary resuscitation (CPR) and the impact of oxygen administration is less clear. We compared ventilation with 100% and 50% oxygen during ineffective manual chest compressions and hypothesized that 100% oxygen would improve brain oxygenation. METHODS Ventricular fibrillation (VF) was induced electrically in anaesthetized pigs and left untreated for 5 minutes, followed by randomization to ineffective manual CPR with ventilation of 50% or 100% oxygen. The first defibrillation was performed 10 minutes after induction of VF, and CPR continued with mechanical chest compressions (LUCAS2™) and defibrillation every 2 minutes until 36 minutes or return of spontaneous circulation (ROSC). Brain oxygenation was measured with near-infrared spectroscopy (rSO2) and invasive brain tissue oxygen (PbtO2) with a probe (NEUROVENT-PTO, RAUMEDIC) inserted into frontal brain tissue. Cerebral oxygenation was compared between groups with Mann-Whitney U tests and linear mixed models. RESULTS Twenty-eight pigs were included in the study: 14 subjects in each group. During ineffective chest compressions relative PbtO2 was higher in the group ventilated with 100% compared to 50% oxygen (5.2 mmHg [1.4-20.5] vs 2.2 [0.8-6.8], p = 0.001), but there was no difference in rSO2 (22% [16-28] vs 18 [15-25], p = 0.090). The use of 50% or 100% oxygen showed no difference in relative PbtO2 (p = 1.00) and rSO2 (p = 0.206) during mechanical CPR. CONCLUSIONS The use of 100% compared to 50% oxygen during ineffective manual CPR improved brain oxygenation measured invasively in brain tissue, but there was no difference in rSO2.
Collapse
Affiliation(s)
- Annika Nelskylä
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jaana Humaloja
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Erik Litonius
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Pirkka Pekkarinen
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Giovanni Babini
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland; Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
| | - Tomi P Mäki-Aho
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Juho A Heinonen
- Division of Intensive Care, Department of Anaesthesiology, Intensive Care, and Pain Medicine, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Markus B Skrifvars
- Department of Emergency Medicine and Services, University of Helsinki and Helsinki University Hospital, Helsinki, Finland.
| |
Collapse
|
6
|
Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [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: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
Collapse
Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| |
Collapse
|
7
|
Ringer SK, Clausen NG, Spielmann N, Weiss M. Effects of hypothermia and hypothermia combined with hypocapnia on cerebral tissue oxygenation in piglets. Paediatr Anaesth 2020; 30:970-976. [PMID: 32506675 DOI: 10.1111/pan.13943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/11/2019] [Revised: 05/26/2020] [Accepted: 05/27/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Hypothermia and its combination with hypocapnia are frequently associated with anesthesia. AIMS The goal was to investigate the effects of hypothermia and hypothermia combined with hypocapnia (hypothermia-hypocapnia) on cerebral tissue oxygenation in anesthetized piglets. METHODS Twenty anesthetized piglets were randomly allocated to hypothermia (n = 10) or hypothermia-hypocapnia (n = 10). Cerebral monitoring comprised a tissue oxygen partial pressure (PtO2 ), a laser Doppler probe, and a near-infrared spectroscopy sensor, measuring regional oxygen saturation (rSO2 ). After baseline recordings, hypothermia (35.5-36.0°C) with or without hypocapnia (target PaCO2 : 28-30 mm Hg) was induced. Once treatment goals were achieved (Tr0), they were maintained for 30 minutes (Tr30). RESULTS No changes in PtO2 but a significant increase in rSO2 (Tr0 (mean difference 8.9[95% CI for difference3.99 to 13.81], P < .001); Tr30 (10.8[6.20 to 15.40], P < .001)) were detected during hypothermia. With hypothermia-hypocapnia, a decrease in PtO2 (Tr0 (-3.2[-6.01 to -0.39], P = .021; Tr30 (-3.3[-5.8 to -0.80], P = .006)) and no significant changes in rSO2 occurred. Cerebral blood flow decreased significantly from baseline to Tr0 independently of treatment (-0.89[-0.18 to -0.002], P = .042), but this was more consistently observed with hypothermia-hypocapnia. CONCLUSIONS The hypothermia-induced reduction in oxygen delivery was compensated by lowered metabolic demand. However, hypothermia was not able to compensate for an additional reduction in oxygen delivery caused by simultaneous hypocapnia. This resulted in a PtO2 drop, which was not reflected by a downshift in rSO2 .
Collapse
Affiliation(s)
- Simone K Ringer
- Department of Clinical Diagnostics and Services, Section Anaesthesiology, Vetsuisse Faculty University of Zurich, Zurich, Switzerland
| | - Nicola G Clausen
- Department of Anaesthesiology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland.,Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Nelly Spielmann
- Department of Anaesthesiology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| | - Markus Weiss
- Department of Anaesthesiology, University Children's Hospital Zurich, Zurich, Switzerland.,Children's Research Centre, University Children's Hospital of Zurich, University of Zurich, Zurich, Switzerland
| |
Collapse
|
8
|
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]
|
9
|
Chen TF, Chen KW, Chien Y, Lai YH, Hsieh ST, Ma HY, Wang KC, Shiau CY. Dental Pulp Stem Cell-Derived Factors Alleviate Subarachnoid Hemorrhage-Induced Neuroinflammation and Ischemic Neurological Deficits. Int J Mol Sci 2019; 20:ijms20153747. [PMID: 31370244 PMCID: PMC6695587 DOI: 10.3390/ijms20153747] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2019] [Revised: 07/25/2019] [Accepted: 07/30/2019] [Indexed: 12/15/2022] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH), characterized by the extravasation of blood into the subarachnoid space caused by an intracranial aneurysm rupture, may lead to neurocognitive impairments and permanent disability and usually carries poor outcome. Dental or gingiva-derived stem cells have been shown to contribute to immune modulation and neuroregeneration, but the underlying mechanisms are unclear. In the present study, we sought to investigate whether dental pulp stem cells (DPSCs) secrete certain factor(s) that can ameliorate the neural damage and other manifestations in a rat aSAH model. Twenty-four hours after the induction of aSAH, microthrombosis, cortical vasoconstriction, and the decrease in microcirculation and tissue oxygen pressure were detected. Intrathecal administration of DPSC-derived conditioned media (DPSC-CM) ameliorated aSAH-induced vasoconstriction, neuroinflammation, and improved the oxygenation in the injured brain. Rotarod test revealed that the aSAH-induced cognitive and motor impairments were significantly improved by this DPSC-CM administration. Cytokine array indicated the major constituent of DPSC-CM was predominantly insulin growth factor-1 (IGF-1). Immunohistochemistry staining of injured brain tissue revealed the robust increase in Iba1-positive cells that were also ameliorated by DPSC-CM administration. Antibody-mediated neutralization of IGF-1 moderately deteriorated the rescuing effect of DPSC-CM on microcirculation, Iba1-positive cells in the injured brain area, and the cognitive/motor impairments. Taken together, the DPSC-derived secretory factors showed prominent therapeutic potential for aSAH. This therapeutic efficacy may include improvement of microcirculation, alleviation of neuroinflammation, and microglial activation; partially through IGF-1-dependent mechanisms.
Collapse
Affiliation(s)
- Te-Fu Chen
- Department of surgery, Division of Neurosurgery, National Taiwan University Hospital, Taipei 100, Taiwan
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan
- Department of Neurosurgery, Tri-Service General Hospital, Taipei 115, Taiwan
- Non-invasive Cancer Therapy Research Institute - Taiwan, Taipei 104, Taiwan
| | - Kuo-We Chen
- Department of surgery, Division of Neurosurgery, National Taiwan University Hospital, Taipei 100, Taiwan
| | - Yueh Chien
- Institute of Pharmacology, School of Medicine, National Yang-Ming University, Taipei 112, Taiwan
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Ying-Hsiu Lai
- Department of Medical Research, Taipei Veterans General Hospital, Taipei 112, Taiwan
| | - Sung-Tsang Hsieh
- Department of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei 102, Taiwan
| | - Hsin-Yi Ma
- Department of Neurosurgery, Tri-Service General Hospital, Taipei 115, Taiwan
| | - Kou-Chung Wang
- Department of surgery, Division of Neurosurgery, National Taiwan University Hospital, Taipei 100, Taiwan.
| | - Chia-Yang Shiau
- Graduate Institute of Medical Sciences, National Defense Medical Center, Taipei 114, Taiwan.
| |
Collapse
|
10
|
Wood MD, Jacobson JA, Maslove DM, Muscedere JG, Boyd JG. The physiological determinants of near-infrared spectroscopy-derived regional cerebral oxygenation in critically ill adults. Intensive Care Med Exp 2019; 7:23. [PMID: 31049754 PMCID: PMC6497723 DOI: 10.1186/s40635-019-0247-0] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/04/2019] [Accepted: 04/07/2019] [Indexed: 02/08/2023] Open
Abstract
Background To maintain adequate oxygen delivery to tissue, resuscitation of critically ill patients is guided by assessing surrogate markers of perfusion. As there is no direct indicator of cerebral perfusion used in routine critical care, identifying an accurate strategy to monitor brain perfusion is paramount. Near-infrared spectroscopy (NIRS) is a non-invasive technique to quantify regional cerebral oxygenation (rSO2) that has been used for decades during cardiac surgery which has led to targeted algorithms to optimize rSO2 being developed. However, these targeted algorithms do not exist during critical care, as the physiological determinants of rSO2 during critical illness remain poorly understood. Materials and methods This prospective observational study was an exploratory analysis of a nested cohort of patients within the CONFOCAL study (NCT02344043) who received high-fidelity vital sign monitoring. Adult patients (≥ 18 years) admitted < 24 h to a medical/surgical intensive care unit were eligible if they had shock and/or required mechanical ventilation. Patients underwent rSO2 monitoring with the FORESIGHT oximeter for 24 h, vital signs were concurrently recorded, and clinically ordered arterial blood gas samples and hemoglobin concentration were also documented. Simultaneous multiple linear regression was performed using all available predictors, followed by model selection using the corrected Akaike information criterion (AICc). Results Our simultaneous multivariate model included age, heart rate, arterial oxygen saturation, mean arterial pressure, pH, partial pressure of oxygen, partial pressure of carbon dioxide (PaCO2), and hemoglobin concentration. This model accounted for a significant proportion of variance in rSO2 (R2 = 0.58, p < 0.01) and was significantly associated with PaCO2 (p < 0.05) and hemoglobin concentration (p < 0.01). Our selected regression model using AICc accounted for a significant proportion of variance in rSO2 (R2 = 0.54, p < 0.01) and was significantly related to age (p < 0.05), PaCO2 (p < 0.01), hemoglobin (p < 0.01), and heart rate (p < 0.05). Conclusions Known and established physiological determinants of oxygen delivery accounted for a significant proportion of the rSO2 signal, which provides evidence that NIRS is a viable modality to assess cerebral oxygenation in critically ill adults. Further elucidation of the determinants of rSO2 has the potential to develop a NIRS-guided resuscitation algorithm during critical illness. Trial registration This trial is registered on clinicaltrials.gov (Identifier: NCT02344043), retrospectively registered January 8, 2015. Electronic supplementary material The online version of this article (10.1186/s40635-019-0247-0) contains supplementary material, which is available to authorized users.
Collapse
Affiliation(s)
- Michael D Wood
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada
| | - Jill A Jacobson
- Department of Psychology, Queen's University, 62 Arch Street, 318 Craine Hall, Kingston, ON, Canada
| | - David M Maslove
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada.,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada
| | - John G Muscedere
- Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada
| | - J Gordon Boyd
- Centre for Neuroscience Studies, Queen's University, 18 Stuart St, Botterell Hall, Kingston, ON, Canada. .,Department of Critical Care Medicine, Queen's University, Rm 22.2.359 Davies 2, Kingston General Hospital, 76 Stuart St, Kingston, ON, K7L 2V7, Canada. .,Department of Medicine, Queen's University, Rm 4.5.310 Watkins C, Kingston General Hospital, 76 Stuart St, Kingston, ON, Canada.
| | | |
Collapse
|
11
|
Wang KC, Tang SC, Lee JE, Tsai JC, Lai DM, Lin WC, Lin CP, Tu YK, Hsieh ST. Impaired microcirculation after subarachnoid hemorrhage in an in vivo animal model. Sci Rep 2018; 8:13315. [PMID: 30190518 PMCID: PMC6127197 DOI: 10.1038/s41598-018-31709-7] [Citation(s) in RCA: 19] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2018] [Accepted: 08/23/2018] [Indexed: 11/16/2022] Open
Abstract
The influence of aneurysmal subarachnoid hemorrhage (SAH) on brain microcirculation has not yet been systematically investigated. We established an animal model to examine (1) the brain surface microcirculation (2) the influences of cerebrospinal fluid (CSF) from aneurysmal SAH on the brain surface microcirculation. A rat SAH model was induced by injection of autologous arterial blood into the cisterna magnum, and the brain surface microcirculation was evaluated by a capillary videoscope with craniotomy at the fronto-parietal region. CSF from SAH rats and SAH patients was applied on the brain surface of naïve rats to assess the resulting microcirculatory changes. In the SAH rats, diffuse constriction of cortical arterioles within 24 hours of SAH was observed. Similar patterns of microcirculation impairment were induced on normal rat brain surfaces via application of CSF from SAH rats and SAH patients. Furthermore, the proportion of subjects with arteriolar vasoconstriction was significantly higher in the group of SAH patients with delayed ischemic neurological deficits (DIND) than in those without DIND (p < 0.001). This study demonstrated impaired microcirculation on brain surface arterioles in a rat model of SAH. CSF from SAH rats and patients was responsible for impairment of brain surface microcirculation.
Collapse
Affiliation(s)
- Kuo-Chuan Wang
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Chun Tang
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan
| | - Jing-Er Lee
- Department of Neurology, Taipei Medical University-Wan Fang Hospital, Taipei, Taiwan
| | - Jui-Chang Tsai
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Dar-Ming Lai
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Wei-Chou Lin
- Department of Pathology, National Taiwan University Hospital, Taipei, Taiwan
| | - Chih-Peng Lin
- Department of Anesthesiology, National Taiwan University Hospital, Taipei, Taiwan
| | - Yong-Kwang Tu
- Division of Neurosurgery, Department of Surgery, National Taiwan University Hospital, Taipei, Taiwan
| | - Sung-Tsang Hsieh
- Department of Neurology, National Taiwan University Hospital, Taipei, Taiwan. .,Department of Anatomy and Cell Biology, College of Medicine, National Taiwan University, Taipei, Taiwan.
| |
Collapse
|
12
|
Mikkelsen MLG, Ambrus R, Rasmussen R, Miles JE, Poulsen HH, Moltke FB, Eriksen T. The influence of norepinephrine and phenylephrine on cerebral perfusion and oxygenation during propofol-remifentanil and propofol-remifentanil-dexmedetomidine anaesthesia in piglets. Acta Vet Scand 2018; 60:8. [PMID: 29422100 PMCID: PMC5806235 DOI: 10.1186/s13028-018-0362-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2017] [Accepted: 01/30/2018] [Indexed: 11/15/2022] Open
Abstract
Background Vasopressors are frequently used to increase blood pressure in order to ensure sufficient cerebral perfusion and oxygenation (CPO) during hypotensive periods in anaesthetized patients. Efficacy depends both on the vasopressor and anaesthetic protocol used. Propofol–remifentanil total intravenous anaesthesia (TIVA) is common in human anaesthesia, and dexmedetomidine is increasingly used as adjuvant to facilitate better haemodynamic stability and analgesia. Little is known of its interaction with vasopressors and subsequent effects on CPO. This study investigates the CPO response to infusions of norepinephrine and phenylephrine in piglets during propofol–remifentanil and propofol–remifentanil–dexmedetomidine anaesthesia. Sixteen healthy female piglets (25–34 kg) were randomly allocated into a two-arm parallel group design with either normal blood pressure (NBP) or induced low blood pressure (LBP). Anaesthesia was induced with propofol without premedication and maintained with propofol–remifentanil TIVA, and finally supplemented with continuous infusion of dexmedetomidine. Norepinephrine and phenylephrine were infused in consecutive intervention periods before and after addition of dexmedetomidine. Cerebral perfusion measured by laser speckle contrast imaging was related to cerebral oxygenation as measured by an intracerebral Licox probe (partial pressure of oxygen) and transcranial near infrared spectroscopy technology (NIRS) (cerebral oxygen saturation). Results During propofol–remifentanil anaesthesia, increases in blood pressure by norepinephrine and phenylephrine did not change cerebral perfusion significantly, but cerebral partial pressure of oxygen (Licox) increased following vasopressors in both groups and increases following norepinephrine were significant (NBP: P = 0.04, LBP: P = 0.02). In contrast, cerebral oxygen saturation (NIRS) fell significantly in NBP following phenylephrine (P = 0.003), and following both norepinephrine (P = 0.02) and phenylephrine (P = 0.002) in LBP. Blood pressure increase by both norepinephrine and phenylephrine during propofol–remifentanil–dexmedetomidine anaesthesia was not followed by significant changes in cerebral perfusion. Licox measures increased significantly following both vasopressors in both groups, whereas the decreases in NIRS measures were only significant in the NBP group. Conclusions Cerebral partial pressure of oxygen measured by Licox increased significantly in concert with the vasopressor induced increases in blood pressure in healthy piglets with both normal and low blood pressure. Cerebral oxygenation assessed by intracerebral Licox and transcranial NIRS showed opposing results to vasopressor infusions. Electronic supplementary material The online version of this article (10.1186/s13028-018-0362-z) contains supplementary material, which is available to authorized users.
Collapse
|
13
|
Nordström CH, Koskinen LO, Olivecrona M. Aspects on the Physiological and Biochemical Foundations of Neurocritical Care. Front Neurol 2017; 8:274. [PMID: 28674514 PMCID: PMC5474476 DOI: 10.3389/fneur.2017.00274] [Citation(s) in RCA: 24] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2017] [Accepted: 05/29/2017] [Indexed: 12/25/2022] Open
Abstract
Neurocritical care (NCC) is a branch of intensive care medicine characterized by specific physiological and biochemical monitoring techniques necessary for identifying cerebral adverse events and for evaluating specific therapies. Information is primarily obtained from physiological variables related to intracranial pressure (ICP) and cerebral blood flow (CBF) and from physiological and biochemical variables related to cerebral energy metabolism. Non-surgical therapies developed for treating increased ICP are based on knowledge regarding transport of water across the intact and injured blood-brain barrier (BBB) and the regulation of CBF. Brain volume is strictly controlled as the BBB permeability to crystalloids is very low restricting net transport of water across the capillary wall. Cerebral pressure autoregulation prevents changes in intracranial blood volume and intracapillary hydrostatic pressure at variations in arterial blood pressure. Information regarding cerebral oxidative metabolism is obtained from measurements of brain tissue oxygen tension (PbtO2) and biochemical data obtained from intracerebral microdialysis. As interstitial lactate/pyruvate (LP) ratio instantaneously reflects shifts in intracellular cytoplasmatic redox state, it is an important indicator of compromised cerebral oxidative metabolism. The combined information obtained from PbtO2, LP ratio, and the pattern of biochemical variables reveals whether impaired oxidative metabolism is due to insufficient perfusion (ischemia) or mitochondrial dysfunction. Intracerebral microdialysis and PbtO2 give information from a very small volume of tissue. Accordingly, clinical interpretation of the data must be based on information of the probe location in relation to focal brain damage. Attempts to evaluate global cerebral energy state from microdialysis of intraventricular fluid and from the LP ratio of the draining venous blood have recently been presented. To be of clinical relevance, the information from all monitoring techniques should be presented bedside online. Accordingly, in the future, the chemical variables obtained from microdialysis will probably be analyzed by biochemical sensors.
Collapse
Affiliation(s)
| | - Lars-Owe Koskinen
- Department of Clinical Neuroscience, Division of Neurosurgery, Umeå University, Umeå, Sweden
| | - Magnus Olivecrona
- Faculty of Health and Medicine, Department of Anesthesia and Intensive Care, Section for Neurosurgery Örebro University Hospital, Örebro University, Örebro, Sweden
- Department for Medical Sciences, Örebro University, Örebro, Sweden
| |
Collapse
|
14
|
Abstract
Traumatic brain injuries (TBIs) in children are a major cause of morbidity and mortality worldwide. Severe TBIs account for 15,000 admissions annually and a mortality rate of 24% in children in the United States. The purpose of this article is to explore pathophysiologic events, examine monitoring techniques, and explain current treatment modalities and nursing care related to caring for children with severe TBI. The primary injury of a TBI is because of direct trauma from an external force, a penetrating object, blast waves, or a jolt to the head. Secondary injury occurs because of alterations in cerebral blood flow, and the development of cerebral edema leads to necrotic and apoptotic cellular death after TBI. Monitoring focuses on intracranial pressure, cerebral oxygenation, cerebral edema, and cerebrovascular injuries. If abnormalities are identified, treatments are available to manage the negative effects caused to the cerebral tissue. The mainstay treatments are hyperosmolar therapy; temperature control; cerebrospinal fluid drainage; barbiturate therapy; decompressive craniectomy; analgesia, sedation, and neuromuscular blockade; and antiseizure prophylaxis.
Collapse
|
15
|
Schiefecker AJ, Beer R, Broessner G, Kofler M, Schmutzhard E, Helbok R. Can Therapeutic Hypothermia Be Guided by Advanced Neuromonitoring in Neurocritical Care Patients? A Review. Ther Hypothermia Temp Manag 2015; 5:126-34. [PMID: 25875898 DOI: 10.1089/ther.2014.0028] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/09/2023] Open
Abstract
The impact of therapeutic hypothermia (TH) on long-term neurological outcome is still controversial. Data on the effects of TH on brain homeostasis are mostly derived from experimental research. Invasive multimodal neuromonitoring techniques may provide additional insight into pathophysiological changes associated with primary or secondary brain injury in humans. In this study we describe the principles of multimodal neuromonitoring and its potential in the clinical setting of TH. We call for more research using multimodal neuromonitoring techniques in patients undergoing TH to optimize cooling and rewarming strategies.
Collapse
Affiliation(s)
- Alois Josef Schiefecker
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Ronny Beer
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Gregor Broessner
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Mario Kofler
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Erich Schmutzhard
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| | - Raimund Helbok
- Division of Neurocritical Care, Department of Neurology, Medical University of Innsbruck , Innsbruck, Austria
| |
Collapse
|
16
|
Kowoll CM, Dohmen C, Kahmann J, Dziewas R, Schirotzek I, Sakowitz OW, Bösel J. Standards of scoring, monitoring, and parameter targeting in German neurocritical care units: a national survey. Neurocrit Care 2014; 20:176-86. [PMID: 23979795 DOI: 10.1007/s12028-013-9893-3] [Citation(s) in RCA: 15] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022]
Abstract
BACKGROUND Optimal management of physiological parameters in neurological/neurosurgical intensive care units (NICUs) is largely unclear as high-quality evidence is lacking. The aim of this survey was to investigate if standards exist in the use of clinical scores, systemic and cerebral monitoring and the targeting of physiology values and in what way this affects clinical management in German NICUs. METHODS National survey, on-line anonymized questionnaire. German departments stating to run a neurological, neurosurgical or interdisciplinary neurological/neurosurgical intensive care unit were identified by a web-based search of all German hospitals and contacted via email. RESULTS Responses from 78 German NICUs were obtained. Of 19 proposed clinical/laboratory/radiological scores only 5 were used regularly by >60 %. Bedside neuromonitoring (NM) predominantly consisted of transcranial Doppler sonography (94 %), electroencephalography (92 %) and measurement of intracranial pressure (ICP) (90 %), and was installed if patients had or were threatened by elevated ICP (86 %), had specific diseases like subarachnoid hemorrhage (51 %) or were comatose (35 %). Although mean trigger values for interventions complied with guidelines or wide-spread customs, individual trigger values varied widely, e.g., for hyperglycemia (maximum blood glucose between 120 and 250 mg/dl) or for anemia (minimum hemoglobin values between 5 and 10 g/dl). CONCLUSIONS Although apparently aiming for standardization in neurocritical care, German NICUs show substantial differences in NM and monitoring-associated interventions. In terms of scoring and monitoring methods, German NICUs seem to be quite conservative. These survey results suggest a need of prospective and randomized interventional trials in neurocritical care to help define standards and target values.
Collapse
Affiliation(s)
- C M Kowoll
- Department of Neurology, University Hospital of Köln, Cologne, Germany
| | | | | | | | | | | | | | | |
Collapse
|
17
|
Manole MD, Kochanek PM, Bayır H, Alexander H, Dezfulian C, Fink EL, Bell MJ, Clark RS. Brain tissue oxygen monitoring identifies cortical hypoxia and thalamic hyperoxia after experimental cardiac arrest in rats. Pediatr Res 2014; 75:295-301. [PMID: 24226633 PMCID: PMC3970819 DOI: 10.1038/pr.2013.220] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/29/2013] [Accepted: 07/04/2013] [Indexed: 11/13/2022]
Abstract
BACKGROUND Optimization of cerebral oxygenation after pediatric cardiac arrest (CA) may reduce neurological damage associated with the post-CA syndrome. We hypothesized that important alterations in regional partial pressure of brain tissue oxygen (PbO2) occur after resuscitation from CA and that clinically relevant interventions such as hyperoxia and blood pressure augmentation would influence PbO2. METHODS Cortical and thalamic PbO2 were monitored in immature rats subjected to asphyxial CA (9 or 12 min asphyxia) and sham-operated rats using oxygen sensors. RESULTS Thalamus and cortex showed similar baseline PbO2. Postresuscitation, there was early and sustained cortical hypoxia in an insult-duration dependent fashion. In contrast, thalamic PbO2 initially increased fourfold and afterwards returned to baseline values. PbO2 level was dependent on the fraction of inspired O2, and the response to oxygen was more pronounced after a 9 vs. 12 min CA. After a 12 min CA, PbO2 was modestly affected by blood pressure augmentation using epinephrine in the thalamus but not in the cortex. CONCLUSION After asphyxial pediatric CA, there is marked regional variability of cerebral oxygenation. Cortical hypoxia is pronounced and appears early, whereas thalamic hyperoxia is followed by normoxia. Compromised PbO2 in the cortex may represent a relevant and clinically measurable therapeutic target aimed at improving neurological outcome after pediatric CA.
Collapse
Affiliation(s)
- Mioara D. Manole
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA
| | - Patrick M. Kochanek
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Hulya Bayır
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Henry Alexander
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Cameron Dezfulian
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Ericka L. Fink
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Michael J. Bell
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| | - Robert S.B. Clark
- Safar Center for Resuscitation Research, University of Pittsburgh, Pittsburgh, PA,Department of Pediatrics, University of Pittsburgh, Pittsburgh, PA,Department of Critical Care Medicine, University of Pittsburgh, Pittsburgh, PA
| |
Collapse
|
18
|
Pandin P, Renard M, Bianchini A, Desjardin P, Obbergh LV. Monitoring Brain and Spinal Cord Metabolism and Function. ACTA ACUST UNITED AC 2014. [DOI: 10.4236/ojanes.2014.46020] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
|
19
|
Le Roux P. Physiological monitoring of the severe traumatic brain injury patient in the intensive care unit. Curr Neurol Neurosci Rep 2013; 13:331. [PMID: 23328942 DOI: 10.1007/s11910-012-0331-2] [Citation(s) in RCA: 40] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of morbidity and mortality worldwide. Despite encouraging animal research, pharmacological agents and neuroprotectants have disappointed in the clinical environment. Current TBI management therefore is directed towards identification, prevention, and treatment of secondary cerebral insults that are known to exacerbate outcome after injury. This strategy is based on a variety of monitoring techniques that include the neurological examination, imaging, laboratory analysis, and physiological monitoring of the brain and other organ systems used to guide therapeutic interventions. Recent clinical series suggest that TBI management informed by multimodality monitoring is associated with improved patient outcome, in part because care is provided in a patient-specific manner. In this review we discuss physiological monitoring of the brain after TBI and the emerging field of neurocritical care bioinformatics.
Collapse
Affiliation(s)
- Peter Le Roux
- Department of Neurosurgery, University of Pennsylvania, 235 South 8th Street, Philadelphia, PA 19106, USA.
| |
Collapse
|
20
|
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
|
21
|
Invasive and noninvasive multimodal bedside monitoring in subarachnoid hemorrhage: a review of techniques and available data. Neurol Res Int 2013; 2013:987934. [PMID: 23606963 PMCID: PMC3628660 DOI: 10.1155/2013/987934] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2012] [Accepted: 03/09/2013] [Indexed: 11/17/2022] Open
Abstract
Delayed-cerebral ischemia is a major cause of morbidity and mortality in the setting of aneurysmal subarachnoid hemorrhage. Despite extensive research efforts and a breadth of collective clinical experience, accurate diagnosis of vasospasm remains difficult, and effective treatment options are limited. Classically, diagnosis has focused on imaging assessment of the cerebral vasculature. Recently, invasive and noninvasive bedside techniques designed to characterize relevant hemodynamic and metabolic alterations have gained substantial attention. Such modalities include microdialysis, brain tissue oxygenation, jugular bulb oximetry, thermal diffusion cerebral blood flow, and near-infrared spectroscopy. This paper reviews these modalities and examines data pertinent to the diagnosis and management of cerebral vasospasm.
Collapse
|
22
|
Katsnelson M, Mackenzie L, Frangos S, Oddo M, Levine JM, Pukenas B, Faerber J, Dong C, Kofke WA, le Roux PD. Are initial radiographic and clinical scales associated with subsequent intracranial pressure and brain oxygen levels after severe traumatic brain injury? Neurosurgery 2012; 70:1095-105; discussion 1105. [PMID: 22076531 DOI: 10.1227/neu.0b013e318240c1ed] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
BACKGROUND Prediction of clinical course and outcome after severe traumatic brain injury (TBI) is important. OBJECTIVE To examine whether clinical scales (Glasgow Coma Scale [GCS], Injury Severity Score [ISS], and Acute Physiology and Chronic Health Evaluation II [APACHE II]) or radiographic scales based on admission computed tomography (Marshall and Rotterdam) were associated with intensive care unit (ICU) physiology (intracranial pressure [ICP], brain tissue oxygen tension [PbtO2]), and clinical outcome after severe TBI. METHODS One hundred one patients (median age, 41.0 years; interquartile range [26-55]) with severe TBI who had ICP and PbtO2 monitoring were identified. The relationship between admission GCS, ISS, APACHE II, Marshall and Rotterdam scores and ICP, PbtO2, and outcome was examined by using mixed-effects models and logistic regression. RESULTS Median (25%-75% interquartile range) admission GCS and APACHE II without GCS scores were 3.0 (3-7) and 11.0 (8-13), respectively. Marshall and Rotterdam scores were 3.0 (3-5) and 4.0 (4-5). Mean ICP and PbtO2 during the patients' ICU course were 15.5 ± 10.7 mm Hg and 29.9 ± 10.8 mm Hg, respectively. Three-month mortality was 37.6%. Admission GCS was not associated with mortality. APACHE II (P = .003), APACHE-non-GCS (P = .004), Marshall (P < .001), and Rotterdam scores (P < .001) were associated with mortality. No relationship between GCS, ISS, Marshall, or Rotterdam scores and subsequent ICP or PbtO2 was observed. The APACHE II score was inversely associated with median PbtO2 (P = .03) and minimum PbtO2 (P = .008) and had a stronger correlation with amount of time of reduced PbtO2. CONCLUSION Following severe TBI, factors associated with outcome may not always predict a patient's ICU course and, in particular, intracranial physiology.
Collapse
Affiliation(s)
- Michael Katsnelson
- Department of Neurology, Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania Medical Center, Philadelphia, Pennsylvania 19106, USA
| | | | | | | | | | | | | | | | | | | |
Collapse
|
23
|
Rohlwink UK, Zwane E, Fieggen AG, Argent AC, le Roux PD, Figaji AA. The relationship between intracranial pressure and brain oxygenation in children with severe traumatic brain injury. Neurosurgery 2012; 70:1220-30; discussion 1231. [PMID: 22134142 DOI: 10.1227/neu.0b013e318243fc59] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Intracranial pressure (ICP) monitoring is a cornerstone of care for severe traumatic brain injury (TBI). Management of ICP can help ensure adequate cerebral blood flow and oxygenation. However, studies indicate that brain hypoxia may occur despite normal ICP and the relationship between ICP and brain oxygenation is poorly defined. This is particularly important for children in whom less is known about intracranial dynamics. OBJECTIVE To examine the relationship between ICP and partial pressure of brain tissue oxygen (PbtO2) in children with severe TBI (Glasgow Coma Scale score ≤ 8) admitted to Red Cross War Memorial Children's Hospital, Cape Town. METHODS The relationship between time-linked hourly and high-frequency ICP and PbtO2 data was examined using correlation, regression, and generalized estimating equations. Thresholds for ICP were examined against reduced PbtO2 using age bands and receiver-operating characteristic curves. RESULTS Analysis using more than 8300 hourly (n = 75) and 1 million high-frequency data points (n = 30) demonstrated a weak relationship between ICP and PbtO2 (r = 0.05 and r = 0.04, respectively). No critical ICP threshold for low PbtO2 was identified. Individual patients revealed a strong relationship between ICP and PbtO2 at specific times, but different relationships were evident over longer periods. CONCLUSION The relationship between ICP and PbtO2 appears complex, and several factors likely influence both variables separately and in combination. Although very high ICP is associated with reduced PbtO2, in general, absolute ICP has a poor relationship with PbtO2. Because reduced PbtO2 is independently associated with poor outcome, a better understanding of ICP and PbtO2 management in pediatric TBI seems to be needed.
Collapse
Affiliation(s)
- Ursula K Rohlwink
- School of Child and Adolescent Health, Division of Neurosurgery, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, Western Cape, South Africa
| | | | | | | | | | | |
Collapse
|
24
|
Physiologic Effects of Xenon in Xenon-CT Cerebral Blood Flow Studies on Comatose Patients. Transl Stroke Res 2012; 3:375-80. [PMID: 24323813 DOI: 10.1007/s12975-012-0183-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2012] [Revised: 04/08/2012] [Accepted: 04/19/2012] [Indexed: 01/17/2023]
Abstract
Despite more than 30 years of clinical use, questions remain about the safety of xenon gas in Xenon-CT cerebral blood flow (XeCTCBF) studies. In particular, xenon's effect on brain oxygen (PbtO2) in comatose patients is not well defined. Our objective was to assess the effect of a 4.5-min inhalation of 28 % stable xenon on several physiologic variables, including intracranial pressure (ICP), cerebral perfusion pressure (CPP), and PbtO2 in comatose patients (Glasgow Coma Scale [GCS] ≤ 8). Thirty-seven comatose patients who underwent 73 XeCTCBF studies were identified retrospectively from a prospective observational database. Changes in MAP, HR, SaO2, EtCO2, ICP, CPP, and PbtO2 measured at the start of xenon administration and every minute for 5 min thereafter were assessed. The maximum change in each variable also was determined for each scan to tabulate clinically relevant changes. Statistically, but not clinically significant changes in MAP, HR, and EtCO2 were seen. Xenon had no effect on ICP, and a small, but clinically insignificant decrease in CPP and PbtO2, was observed. There was a varied response to xenon in most measured variables. Clinically significant changes in each were infrequent, and readily reversed with the cessation of the gas. We conclude that xenon does not appear to have a clinically significant effect on ICP, CPP, and PbtO2 and so appears safe to evaluate cerebral blood flow in comatose patients.
Collapse
|
25
|
Helbok R, Schiefecker A, Fischer M, Dietmann A, Schmutzhard E. Hypothermia and advanced neuromonitoring. Crit Care 2012. [PMCID: PMC3389487 DOI: 10.1186/cc11285] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/10/2022] Open
|
26
|
Nielsen TH, Engell SI, Johnsen RA, Schulz MK, Gerke O, Hjelmborg J, Toft P, Nordström CH. Comparison between cerebral tissue oxygen tension and energy metabolism in experimental subdural hematoma. Neurocrit Care 2012; 15:585-92. [PMID: 21638119 DOI: 10.1007/s12028-011-9563-2] [Citation(s) in RCA: 10] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND An experimental swine model (n = 7) simulating an acute subdural hematoma (ASDH) was employed (1) to explore the relation between the brain tissue oxygenation (PbtO(2)) and the regional cerebral energy metabolism as obtained by microdialysis, and (2) to define the lowest level of PbtO(2) compatible with intact energy metabolism. METHODS ASDH was produced by infusion of 7 ml of autologous blood (infusion rate 0.5 ml/min) by a catheter placed subdurally. PbtO(2) and microdialysis probes were placed symmetrically in the injured ("bad-side") and non-injured ("good-side") hemispheres. Intracranial pressure (ICP) was monitored in the "good-side." RESULTS ICP, cerebral perfusion pressure (CPP), PbtO(2), glucose, lactate, pyruvate, lactate-pyruvate ratio (LP ratio), glutamate, and glycerol were recorded at baseline (60 min) and post trauma (360 min). After the creation of the ASDH, PbtO(2) decreased significantly in both the hemispheres (P < 0.001). No significant difference was found between the sides post trauma. The LP ratio, glutamate, and glycerol in the "bad-side" increased significantly over the "good-side" where the values remained within the normal limits. A PbtO(2) value below approximately 25 mmHg was found to be associated with disturbed energy metabolism in the "bad-side" but not in the "good-side." No correlation was found between the LP ratio and PbtO(2) in either hemisphere. CONCLUSIONS PbtO(2) monitoring accurately describes tissue oxygenation but does not disclose whether the oxygen delivery is sufficient for maintaining cerebral energy metabolism. Accordingly, it may not be possible to define a threshold level for PbtO(2) below which energy failure and permanent tissue damage occurs.
Collapse
Affiliation(s)
- Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Sdr. Boulevard 29, 5000 Odense C, Denmark.
| | | | | | | | | | | | | | | |
Collapse
|
27
|
Wijman CAC, Smirnakis SM, Vespa P, Szigeti K, Ziai WC, Ning MM, Rosand J, Hanley DF, Geocadin R, Hall C, Le Roux PD, Suarez JI, Zaidat OO. Research and technology in neurocritical care. Neurocrit Care 2012; 16:42-54. [PMID: 21796494 DOI: 10.1007/s12028-011-9609-5] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
The daily practice of neurointensivists focuses on the recognition of subtle changes in the neurological examination, interactions between the brain and systemic derangements, and brain physiology. Common alterations such as fever, hyperglycemia, and hypotension have different consequences in patients with brain insults compared with patients of general medical illness. Various technologies have become available or are currently being developed. The session on "research and technology" of the first neurocritical care research conference held in Houston in September of 2009 was devoted to the discussion of the current status, and the research role of state-of-the art technologies in neurocritical patients including multi-modality neuromonitoring, biomarkers, neuroimaging, and "omics" research (proteomix, genomics, and metabolomics). We have summarized the topics discussed in this session. We have provided a brief overview of the current status of these technologies, and put forward recommendations for future research applications in the field of neurocritical care.
Collapse
Affiliation(s)
- C A C Wijman
- Department of Neurology, Stanford University, Palo Alto, CA, USA.
| | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
28
|
Abstract
Several non-invasive and invasive modalities have been used to monitor patients for cerebral ischemia after subarachnoid hemorrhage. A literature search was performed to identify original research studies testing monitors that may be used in addition to the standard measures of brain function and cerebral blood flow. Fifty observational studies were identified that evaluated the role of electroencephalography, brain tissue oxygenation monitoring, cerebral microdialysis, thermal diffusion flowmetry, or near-infrared spectroscopy in patients after subarachnoid hemorrhage.
Collapse
|
29
|
Schmidt JM, Claassen J. Clinical utility of brain tissue oxygen tension in treatment of brain injury more complicated than it appears. Clin Neurophysiol 2011; 123:1060-2. [PMID: 22119796 DOI: 10.1016/j.clinph.2011.10.009] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2011] [Revised: 10/14/2011] [Accepted: 10/19/2011] [Indexed: 10/15/2022]
|
30
|
|
31
|
Current world literature. Curr Opin Anaesthesiol 2011; 24:224-33. [PMID: 21386670 DOI: 10.1097/aco.0b013e32834585d6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
|
32
|
Abstract
PURPOSE OF REVIEW This review focuses on the role of various intracranial monitoring technologies in the diagnosis and therapy of traumatic brain injury injury. RECENT FINDINGS There exist many controversial points as to the utility of different intracranial monitoring with regard to improvement of outcomes from severe traumatic brain injury. Most recent studies are confirming that the use of multiple modalities in the neurological ICU setting may offer promising results. SUMMARY Increased adherence to guideline-based and protocol-driven neurointensive care utilizing multimodality in monitoring technology for patients with severe traumatic brain injury is likely to give clinicians increased insight into the elusive mechanisms underlying the complex pathophysiology of this disease process and may further improve outcomes in this patient population.
Collapse
|
33
|
Chen HI, Stiefel MF, Oddo M, Milby AH, Maloney-Wilensky E, Frangos S, Levine JM, Kofke WA, LeRoux PD. Detection of Cerebral Compromise With Multimodality Monitoring in Patients With Subarachnoid Hemorrhage. Neurosurgery 2011; 69:53-63; discussion 63. [DOI: 10.1227/neu.0b013e3182191451] [Citation(s) in RCA: 97] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Abstract
Abstract
BACKGROUND:
Studies in traumatic brain injury suggest that monitoring techniques such as brain tissue oxygen (Pbto2) and cerebral microdialysis may complement conventional intracranial pressure (ICP) and cerebral perfusion pressure (CPP) measurements.
OBJECTIVE:
In this study of poor-grade (Hunt and Hess grade IV and V) subarachnoid hemorrhage (SAH) patients, we examined the prevalence of brain hypoxia and brain energy dysfunction in the presence of normal and abnormal ICP and CPP.
METHODS:
SAH patients who underwent multimodal neuromonitoring and cerebral microdialysis were studied. We examined the frequency of brain hypoxia and energy dysfunction in different ICP and CPP ranges and the relationship between Pbto2 and the lactate/pyruvate ratio (LPR).
RESULTS:
A total of 2394 samples from 19 patients were analyzed. There were 149 samples with severe brain hypoxia (Pbto2 ≤10 mm Hg) and 347 samples with brain energy dysfunction (LPR >40). The sensitivities of abnormal ICP or CPP for elevated LPR and reduced Pbto2 were poor (21.2% at best), and the LPR or Pbto2 was abnormal in many instances when ICP or CPP was normal. Severe brain hypoxia was often associated with an LPR greater than 40 (86% of samples). In contrast, mild brain hypoxia (≤20 mm Hg) and severe brain hypoxia were observed in only 53% and 36% of samples with brain energy dysfunction, respectively.
CONCLUSION:
Our data demonstrate that ICP and CPP monitoring may not always detect episodes of cerebral compromise in SAH patients. Our data suggest that several complementary monitors may be needed to optimize the care of poor-grade SAH patients.
Collapse
Affiliation(s)
- H Isaac Chen
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Michael F Stiefel
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Mauro Oddo
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Andrew H Milby
- Departments of University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Eileen Maloney-Wilensky
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Suzanne Frangos
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Joshua M Levine
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Departments of Neurology, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Departments of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - W Andrew Kofke
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
- Departments of Anesthesiology and Critical Care, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| | - Peter D LeRoux
- Departments of Neurosurgery,, Hospital of the University of Pennsylvania, Philadelphia, Pennsylvania
| |
Collapse
|