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Sakas R, Dan K, Edelman D, Abu-Ata S, Ben-Menashe A, Awad-Igbaria Y, Francois-Soustiel J, Palzur E. Hyperbaric Oxygen Therapy Alleviates Memory and Motor Impairments Following Traumatic Brain Injury via the Modulation of Mitochondrial-Dysfunction-Induced Neuronal Apoptosis in Rats. Antioxidants (Basel) 2023; 12:2034. [PMID: 38136154 PMCID: PMC10740762 DOI: 10.3390/antiox12122034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2023] [Revised: 11/07/2023] [Accepted: 11/20/2023] [Indexed: 12/24/2023] Open
Abstract
Traumatic brain injury (TBI) is a leading cause of morbidity and mortality in young adults, characterized by primary and secondary injury. Primary injury is the immediate mechanical damage, while secondary injury results from delayed neuronal death, often linked to mitochondrial damage accumulation. Hyperbaric oxygen therapy (HBOT) has been proposed as a potential treatment for modulating secondary post-traumatic neuronal death. However, the specific molecular mechanism by which HBOT modulates secondary brain damage through mitochondrial protection remains unclear. Spatial learning, reference memory, and motor performance were measured in rats before and after Controlled Cortical Impact (CCI) injury. The HBOT (2.5 ATA) was performed 4 h following the CCI and twice daily (12 h intervals) for four consecutive days. Mitochondrial functions were assessed via high-resolution respirometry on day 5 following CCI. Moreover, IHC was performed at the end of the experiment to evaluate cortical apoptosis, neuronal survival, and glial activation. The current result indicates that HBOT exhibits a multi-level neuroprotective effect. Thus, we found that HBOT prevents cortical neuronal loss, reduces the apoptosis marker (cleaved-Caspase3), and modulates glial cell proliferation. Furthermore, HBO treatment prevents the reduction in mitochondrial respiration, including non-phosphorylation state, oxidative phosphorylation, and electron transfer capacity. Additionally, a superior motor and spatial learning performance level was observed in the CCI group treated with HBO compared to the CCI group. In conclusion, our findings demonstrate that HBOT during the critical period following the TBI improves cognitive and motor damage via regulating glial proliferation apoptosis and protecting mitochondrial function, consequently preventing cortex neuronal loss.
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Affiliation(s)
- Reem Sakas
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Katya Dan
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Doron Edelman
- Neurosurgery Department, Tel-Aviv Sourasky Medical Center, Tel-Aviv 6423906, Israel;
| | - Saher Abu-Ata
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Aviv Ben-Menashe
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Yaseen Awad-Igbaria
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
| | - Jean Francois-Soustiel
- Azrieli Faculty of Medicine, Bar-Ilan University, Safed 1311502, Israel; (R.S.); (K.D.); (S.A.-A.); (A.B.-M.); (J.F.-S.)
- Neurosurgery Department, Galilee Medical Center, Nahariya 221001, Israel
| | - Eilam Palzur
- Research Institute of Galilee Medical Center, Nahariya 221001, Israel
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Sivashankar S A, Swamiyappan SS, Visweswaran V, Bathala RT, Krishnaswamy V, Davuluri VS, Sridhar A, K G. Biochemical and Radiological Factors for Prognostication of Traumatic Brain Injury: An Institutional Experience. Cureus 2023; 15:e40999. [PMID: 37503475 PMCID: PMC10371385 DOI: 10.7759/cureus.40999] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/26/2023] [Indexed: 07/29/2023] Open
Abstract
Introduction Traumatic brain injury (TBI) necessitates identifying patients at risk of fatal outcomes. Classic biomarkers used clinically today in other organ systems are quantitative in nature. This aspect largely restricts the prognostic ability of a theoretical quantitative brain biomarker. This study aimed to explore biochemical markers and imaging findings reflecting the severity of cerebral damage to predict outcomes. Methodology In this study, 61 TBI cases with moderate to severe brain injury were prospectively observed, and various indices including random blood sugar (RBS), hemoglobin, international normalized ratio (INR), lactate dehydrogenase (LDH), cortisol, and CT findings were assessed. Glasgow Outcome Scores (GOS) determined the outcomes. Statistical analysis was carried out to assess correlations. Results The mean RBS level of those who did not survive was 259.58 mg/dL, whereas in those who survived the value was 158.48 mg/dL. Analysis indicated that patients with high RBS value on admission had a higher risk of mortality (p=0.000). We noted that the mean serum cortisol levesl on both Days 1 and 5 were higher in patients who died and were able to establish a statistically significant correlation between both the values and outcome. A statistically significant negative correlation between Day 1 and Day 5 serum LDH levels and outcomes was evident from our study (p=0.000 for both). Among the components of the Rotterdam score, the presence of intraventricular hemorrhage (IVH) in the CT scan had a significant association with unfavorable outcomes (p=0.01) while midline shift was significantly associated with a low GCS (p=0.04). Conclusion Biochemical markers such as INR, RBS, serum cortisol, and LDH at admission can serve as valuable indicators of prognosis in TBI patients. Furthermore, a persistent increase in LDH and cortisol levels between Days 1 and 5, along with the Glasgow Coma Scale and Rotterdam Scoring system, are good predictors of mortality.
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Affiliation(s)
- Abinav Sivashankar S
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | | | - Vivek Visweswaran
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Rav Tej Bathala
- Neurosurgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | | | | | - Ashwin Sridhar
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
| | - Ganesh K
- Neurological Surgery, Sri Ramachandra Institute of Higher Education and Research, Chennai, IND
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Denchev K, Gomez J, Chen P, Rosenblatt K. Traumatic Brain Injury: Intraoperative Management and Intensive Care Unit Multimodality Monitoring. Anesthesiol Clin 2023; 41:39-78. [PMID: 36872007 DOI: 10.1016/j.anclin.2022.11.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Traumatic brain injury is a devastating event associated with substantial morbidity. Pathophysiology involves the initial trauma, subsequent inflammatory response, and secondary insults, which worsen brain injury severity. Management entails cardiopulmonary stabilization and diagnostic imaging with targeted interventions, such as decompressive hemicraniectomy, intracranial monitors or drains, and pharmacological agents to reduce intracranial pressure. Anesthesia and intensive care requires control of multiple physiologic variables and evidence-based practices to reduce secondary brain injury. Advances in biomedical engineering have enhanced assessments of cerebral oxygenation, pressure, metabolism, blood flow, and autoregulation. Many centers employ multimodality neuromonitoring for targeted therapies with the hope to improve recovery.
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Affiliation(s)
- Krassimir Denchev
- Department of Anesthesiology, Wayne State University, 44555 Woodward Avenue, SJMO Medical Office Building, Suite 308, Pontiac, MI 48341, USA
| | - Jonathan Gomez
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA
| | - Pinxia Chen
- Department of Anesthesiology and Critical Care Medicine, St. Luke's University Health Network, 801 Ostrum Street, Bethlehem, PA 18015, USA
| | - Kathryn Rosenblatt
- Department of Anesthesiology & Critical Care Medicine, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA; Department of Neurology, Johns Hopkins University School of Medicine, 600 North Wolfe Street, Phipps 455, Baltimore, MD 21287, USA.
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Venturini S, Bhatti F, Timofeev I, Carpenter KLH, Hutchinson PJ, Guilfoyle MR, Helmy A. Microdialysis-Based Classifications of Abnormal Metabolic States after Traumatic Brain Injury: A Systematic Review of the Literature. J Neurotrauma 2023; 40:195-209. [PMID: 36112699 DOI: 10.1089/neu.2021.0502] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
After traumatic brain injury (TBI), cerebral metabolism can become deranged, contributing to secondary injury. Cerebral microdialysis (CMD) allows cerebral metabolism assessment and is often used with other neuro-monitoring modalities. CMD-derived parameters such as the lactate/pyruvate ratio (LPR) show a failure of oxidative energy generation. CMD-based abnormal metabolic states can be described following TBI, informing the etiology of physiological derangements. This systematic review summarizes the published literature on microdialysis-based abnormal metabolic classifications following TBI. Original research studies in which the populations were patients with TBI were included. Studies that described CMD-based classifications of metabolic abnormalities were included in the synthesis of the narrative results. A total of 825 studies underwent two-step screening after duplicates were removed. Fifty-three articles that used CMD in TBI patients were included. Of these, 14 described abnormal metabolic states based on CMD parameters. Classifications were heterogeneous between studies. LPR was the most frequently used parameter in the classifications; high LPR values were described as metabolic crisis. Ischemia was consistently defined as high LPR with low CMD substrate levels (glucose or pyruvate). Mitochondrial dysfunction, describing inability to use energy substrate despite availability, was identified based on raised LPR with near-normal levels of pyruvate. This is the first systematic review summarizing the published literature on microdialysis-based abnormal metabolic states following TBI. Although variability exists among individual classifications, there is broad agreement about broad definitions of metabolic crisis, ischemia, and mitochondrial dysfunction. Identifying the etiology of deranged cerebral metabolism after TBI is important for targeting therapeutic interventions.
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Affiliation(s)
- Sara Venturini
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Faheem Bhatti
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ivan Timofeev
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Keri L H Carpenter
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
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Raman Spectroscopy as a Tool to Study the Pathophysiology of Brain Diseases. Int J Mol Sci 2023; 24:ijms24032384. [PMID: 36768712 PMCID: PMC9917237 DOI: 10.3390/ijms24032384] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2022] [Revised: 01/16/2023] [Accepted: 01/18/2023] [Indexed: 01/27/2023] Open
Abstract
The Raman phenomenon is based on the spontaneous inelastic scattering of light, which depends on the molecular characteristics of the dispersant. Therefore, Raman spectroscopy and imaging allow us to obtain direct information, in a label-free manner, from the chemical composition of the sample. Since it is well established that the development of many brain diseases is associated with biochemical alterations of the affected tissue, Raman spectroscopy and imaging have emerged as promising tools for the diagnosis of ailments. A combination of Raman spectroscopy and/or imaging with tagged molecules could also help in drug delivery and tracing for treatment of brain diseases. In this review, we first describe the basics of the Raman phenomenon and spectroscopy. Then, we delve into the Raman spectroscopy and imaging modes and the Raman-compatible tags. Finally, we center on the application of Raman in the study, diagnosis, and treatment of brain diseases, by focusing on traumatic brain injury and ischemia, neurodegenerative disorders, and brain cancer.
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Prolonged and intense neuroinflammation after severe traumatic brain injury assessed by cerebral microdialysis with 300 kDa membranes. J Neuroimmunol 2023; 377:578020. [PMID: 36931209 DOI: 10.1016/j.jneuroim.2023.578020] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2022] [Revised: 01/04/2023] [Accepted: 01/13/2023] [Indexed: 01/19/2023]
Abstract
BACKGROUND A neuroinflammatory response that may lead to edema and secondary brain damage is elicited in severe traumatic brain injury (TBI). Previous studies using microdialysis (MD) membranes with 100 k Dalton (kDa) cut-off found a transient intracerebral release of cytokines and chemokines without significant correlations to clinical course, intracranial pressure (ICP) or metabolites. In this study, a (300 kDa) MD probe was used to measure the levels of cytokines and chemokines in relation to ICP and metabolites. METHODS Seven patients with severe TBI received 2 MD catheters. In four patients sufficient dialysate could be retrieved for analysis from both catheters. MD samples were analyzed bedside, then frozen and analyzed for chemokines and cytokines using a multiplex assay (Mesoscale Discovery). RESULTS MD sampling was performed from 9 to 350 h. In total, 17 chemokines and cytokines were detected. Of these, IL-6, IL-8, IP-10, MCP-1 and MIP-1β were consistently elevated, and investigated further in relation to metabolites, and ICP. Levels of chemokines and cytokines were higher than previously reported from TBI patients, and partially higher than those reported in patients with cytokine release syndrome. There were no significant differences between the two catheters regarding cytokine/chemokine concentrations, except for IL-6 which was higher in the peri-contusional area. No correlation with metabolites and ICP was observed. No significant increase or decline of chemokine or cytokine secretion was observed during the study period. CONCLUSION Our data suggest that cytokine and chemokine levels reflect a perpetual, potent and pan-cerebebral inflammatory response that persists beyond 15 days following TBI.
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Falcone JA, Chen JW. Technical notes on the placement of cerebral microdialysis: A single center experience. Front Neurol 2023; 13:1041952. [PMID: 36698903 PMCID: PMC9868911 DOI: 10.3389/fneur.2022.1041952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023] Open
Abstract
Background Cerebral microdialysis enables monitoring of brain metabolism and can be an important part of multimodal monitoring strategies in a variety of brain injuries. Microdialysis catheters can be placed in brain parenchyma through a burr hole, a cranial bolt, or directly at the time of an open craniotomy or craniectomy. The location of catheters in relation to brain pathology is important to the interpretation of data and guidance of interventions. Methods Here we retrospectively review the use of cerebral microdialysis at a US Regional Medical Center between March 2018 and February 2022 and provide detailed descriptions and technical nuances of the different methods to place microdialysis catheters. Results Eighty two unique microdialysis catheters were utilized in 52 patients. 35 (42.68%) were placed via a quad-lumen bolt and 47 (57.32%) were placed through craniotomies. 27 catheters (32.93%) were placed in a perilesional location, 50 (60.98%) were located in healthy tissue, and 6 (7.32%) were mispositioned. No significant difference was seen between placement by bolt or craniotomy in regard to perilesional location, mispositioning, or complications. Conclusion With careful planning and thoughtful execution, cerebral microdialysis catheters can be successfully placed though a variety of strategies to optimize and individualize brain monitoring in different clinical settings. This paper provides a detailed guide for the various methods of catheter placement to help providers begin or expand their use of cerebral microdialysis.
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Grech O, Seneviratne SY, Alimajstorovic Z, Yiangou A, Mitchell JL, Smith TB, Mollan SP, Lavery GG, Ludwig C, Sinclair AJ. Nuclear Magnetic Resonance Spectroscopy Metabolomics in Idiopathic Intracranial Hypertension to Identify Markers of Disease and Headache. Neurology 2022; 99:e1702-e1714. [PMID: 36240084 PMCID: PMC9620805 DOI: 10.1212/wnl.0000000000201007] [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: 01/09/2022] [Accepted: 06/09/2022] [Indexed: 11/15/2022] Open
Abstract
BACKGROUND AND OBJECTIVE We evaluated the metabolomic profile in the CSF, serum, and urine of participants with idiopathic intracranial hypertension (IIH) compared with that in controls and measured changes in metabolism associated with clinical markers of disease activity and treatment. METHODS A case-control study compared women aged 18-55 years with active IIH (Friedman diagnostic criteria) with a sex-matched, age-matched, and body mass index-matched control group. IIH participants were identified from neurology and ophthalmology clinics from National Health Service hospitals and underwent a prospective intervention to induce disease remission through weight loss with reevaluation at 12 months. Clinical assessments included lumbar puncture, headache, papilledema, and visual measurements. Spectra of the CSF, serum, and urine metabolites were acquired using proton nuclear magnetic resonance spectroscopy. RESULTS Urea was lower in IIH participants (CSF, controls median ± IQR 0.196 ± 0.008, IIH 0.058 ± 0.059, p < 0.001; urine, controls 5971.370 ± 3021.831, IIH 4691.363 ± 1955.774, p = 0.009), correlated with ICP (urine p = 0.019) and headache severity (CSF p = 0.031), and increased by 12 months (CSF 12 months; 0.175 ± 0.043, p = 0.004, urine; 5210.874 ± 1825.302, p = 0.043). The lactate:pyruvate ratio was increased in IIH participants compared with that in controls (CSF, controls 49.739 ± 19.523, IIH 113.114 ± 117.298, p = 0.023; serum, controls 38.187 ± 13.392, IIH 54.547 ± 18.471, p = 0.004) and decreased at 12 months (CSF, 113.114 ± 117.298, p < 0.001). Baseline acetate was higher in IIH participants (CSF, controls 0.128 ± 0.041, IIH 0.192 ± 0.151, p = 0.008), correlated with headache severity (p = 0.030) and headache disability (p = 0.003), and was reduced at 12 months (0.160 ± 0.060, p = 0.007). Ketones, 3-hydroxybutyrate and acetoacetate, were altered in the CSF at baseline in IIH participants (3-hydroxybutyrate, controls 0.074 ± 0.063, IIH 0.049 ± 0.055, p = 0.019; acetoacetate, controls 0.013 ± 0.007, IIH 0.017 ± 0.010, p = 0.013) and normalized at 12 months (0.112 ± 0.114, p = 0.019, 0.029 ± 0.017, p = 0.015, respectively). DISCUSSION We observed metabolic disturbances that are evident in the CSF, serum, and urine of IIH participants, suggesting global metabolic dysregulation. Altered ketone body metabolites normalized after therapeutic weight loss. CSF:serum urea ratio was altered, which may influence ICP dynamics and headache. Elevated CSF acetate, known to stimulate trigeminal sensitization, was associated with headache morbidity. These alterations of metabolic pathways specific to IIH provide biological insight and warrant mechanistic evaluation. TRIAL REGISTRATION INFORMATION Registered on ClinicalTrials.gov, NCT02124486 (submitted April 22, 2014) and NCT02017444 (submitted December 16, 2013).
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Affiliation(s)
- Olivia Grech
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Senali Y Seneviratne
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Zerin Alimajstorovic
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Andreas Yiangou
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - James L Mitchell
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Thomas B Smith
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Susan P Mollan
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Gareth G Lavery
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Christian Ludwig
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK
| | - Alexandra J Sinclair
- Metabolic Neurology (O.G., S.Y.S., Z.A., A.Y., J.L.M., A.J.S.), Institute of Metabolism and Systems Research, College of Medical and Dental Sciences, University of Birmingham; Department of Neurology (A.Y., J.L.M., A.J.S.), University Hospitals Birmingham NHS Foundation Trust; Department of Surgery (T.B.S.), Addenbrooke's Hospital, The University of Cambridge; Birmingham Neuro-Ophthalmology (S.P.M), Queen Elizabeth Hospital, University Hospitals Birmingham; Institute of Metabolism and Systems Research (G.G.L., C.L.), College of Medical and Dental Sciences, University of Birmingham; and Department of Biosciences (G.G.L.), School of Science and Technology, Nottingham Trent University, Clifton Campus, UK.
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Lindholm E, Bergmann GB, Haugaa H, Labori KJ, Yaqub S, Bjørnbeth BA, Line PD, Grindheim G, Kjøsen G, Pischke SE, Tønnessen TI. Early detection of anastomotic leakage after pancreatoduodenectomy with microdialysis catheters: an observational Study. HPB (Oxford) 2022; 24:901-909. [PMID: 34836755 DOI: 10.1016/j.hpb.2021.10.020] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2020] [Revised: 08/05/2021] [Accepted: 10/29/2021] [Indexed: 12/12/2022]
Abstract
BACKGROUND Microdialysis catheters can detect focal inflammation and ischemia, and thereby have a potential for early detection of anastomotic leakages after pancreatoduodenectomy. The aim was to investigate whether microdialysis catheters placed near the pancreaticojejunostomy can detect leakage earlier than the current standard of care. METHODS Thirty-five patients with a median age 69 years were included. Two microdialysis catheters were placed at the end of surgery; one at the pancreaticojejunostomy, and one at the hepaticojejunostomy. Concentrations of glucose, lactate, pyruvate, and glycerol were analyzed hourly in the microdialysate during the first 24 h, and every 2-4 h thereafter. RESULTS Seven patients with postoperative pancreatic fistulae (POPF) had significantly higher glycerol levels (P < 0.01) in the microdialysate already in the first postoperative samples. Glycerol concentrations >400 μmol/L during the first 12 postoperative hours detected patients with POPF with a sensitivity of 100% and a specificity of 93% (P < 0.001). After 24 h, lactate and lactate-to-pyruvate ratio were significantly higher (P < 0.05) and glucose was significantly lower (P < 0.05) in patients with POPF. CONCLUSION High levels of glycerol in microdialysate was an early detector of POPF. The subsequent inflammation was detected as increase in lactate and lactate-to-pyruvate ratio and a decrease in glucose (NCT03627559).
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Affiliation(s)
- Espen Lindholm
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Clinic of Surgery, Vestfold Hospital Trust, 3103 Tønsberg, Norway
| | - Gisli Björn Bergmann
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway
| | - Håkon Haugaa
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Lovisenberg Diaconal University College, 0456 Oslo, Norway
| | - Knut Jørgen Labori
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Sheraz Yaqub
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Bjørn Atle Bjørnbeth
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway
| | - Pål-Dag Line
- Department of Hepato-Pancreato-Biliary Surgery, Division of Surgery, Inflammatory Medicine and Transplantation, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway
| | - Guro Grindheim
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway
| | - Gisle Kjøsen
- Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway; Department of Research and Development, Division of Emergencies and Critical Care, Oslo University Hospital, Norway
| | - Søren Erik Pischke
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway; Department of Immunology, Oslo University Hospital, 0454 Oslo, Norway
| | - Tor Inge Tønnessen
- Department of Anaesthesiology, Division of Emergencies and Critical Care, Oslo University Hospital, 0454 Oslo, Norway; Institute of Clinical Medicine, University of Oslo, 0316, Oslo, Norway.
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10
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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.
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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
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11
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Stevens AR, Stickland CA, Harris G, Ahmed Z, Goldberg Oppenheimer P, Belli A, Davies DJ. Raman Spectroscopy as a Neuromonitoring Tool in Traumatic Brain Injury: A Systematic Review and Clinical Perspectives. Cells 2022; 11:1227. [PMID: 35406790 PMCID: PMC8997459 DOI: 10.3390/cells11071227] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2022] [Revised: 04/01/2022] [Accepted: 04/04/2022] [Indexed: 12/22/2022] Open
Abstract
Traumatic brain injury (TBI) is a significant global health problem, for which no disease-modifying therapeutics are currently available to improve survival and outcomes. Current neuromonitoring modalities are unable to reflect the complex and changing pathophysiological processes of the acute changes that occur after TBI. Raman spectroscopy (RS) is a powerful, label-free, optical tool which can provide detailed biochemical data in vivo. A systematic review of the literature is presented of available evidence for the use of RS in TBI. Seven research studies met the inclusion/exclusion criteria with all studies being performed in pre-clinical models. None of the studies reported the in vivo application of RS, with spectral acquisition performed ex vivo and one performed in vitro. Four further studies were included that related to the use of RS in analogous brain injury models, and a further five utilised RS in ex vivo biofluid studies for diagnosis or monitoring of TBI. RS is identified as a potential means to identify injury severity and metabolic dysfunction which may hold translational value. In relation to the available evidence, the translational potentials and barriers are discussed. This systematic review supports the further translational development of RS in TBI to fully ascertain its potential for enhancing patient care.
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Affiliation(s)
- Andrew R. Stevens
- Neuroscience, Trauma and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (Z.A.); (A.B.); (D.J.D.)
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham B15 2TH, UK
| | - Clarissa A. Stickland
- School of Chemical Engineering, University of Birmingham, Birmingham B15 2TT, UK; (C.A.S.); (G.H.); (P.G.O.)
| | - Georgia Harris
- School of Chemical Engineering, University of Birmingham, Birmingham B15 2TT, UK; (C.A.S.); (G.H.); (P.G.O.)
| | - Zubair Ahmed
- Neuroscience, Trauma and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (Z.A.); (A.B.); (D.J.D.)
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham B15 2TH, UK
- Centre for Trauma Science Research, University of Birmingham, Birmingham B15 2TT, UK
| | - Pola Goldberg Oppenheimer
- School of Chemical Engineering, University of Birmingham, Birmingham B15 2TT, UK; (C.A.S.); (G.H.); (P.G.O.)
| | - Antonio Belli
- Neuroscience, Trauma and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (Z.A.); (A.B.); (D.J.D.)
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham B15 2TH, UK
- Centre for Trauma Science Research, University of Birmingham, Birmingham B15 2TT, UK
| | - David J. Davies
- Neuroscience, Trauma and Ophthalmology, Institute of Inflammation and Ageing, University of Birmingham, Birmingham B15 2TT, UK; (Z.A.); (A.B.); (D.J.D.)
- NIHR Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham, Birmingham B15 2TH, UK
- Centre for Trauma Science Research, University of Birmingham, Birmingham B15 2TT, UK
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12
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Hu Y, Tao W. Microenvironmental Variations After Blood-Brain Barrier Breakdown in Traumatic Brain Injury. Front Mol Neurosci 2021; 14:750810. [PMID: 34899180 PMCID: PMC8662751 DOI: 10.3389/fnmol.2021.750810] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2021] [Accepted: 10/18/2021] [Indexed: 12/12/2022] Open
Abstract
Traumatic brain injury (TBI) is linked to several pathologies. The blood-brain barrier (BBB) breakdown is considered to be one of the initial changes. Further, the microenvironmental alteration following TBI-induced BBB breakdown can be multi-scaled, constant, and dramatic. The microenvironmental variations after disruption of BBB includes several pathological changes, such as cerebral blood flow (CBF) alteration, brain edema, cerebral metabolism imbalances, and accumulation of inflammatory molecules. The modulation of the microenvironment presents attractive targets for TBI recovery, such as reducing toxic substances, inhibiting inflammation, and promoting neurogenesis. Herein, we briefly review the pathological alterations of the microenvironmental changes following BBB breakdown and outline potential interventions for TBI recovery based on microenvironmental modulation.
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Affiliation(s)
- Yue Hu
- School of Chinese Medicine, School of Integrated Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China
| | - Weiwei Tao
- School of Chinese Medicine, School of Integrated Chinese and Western Medicine, Nanjing University of Chinese Medicine, Nanjing, China.,Jiangsu Collaborative Innovation Center of Chinese Medicinal Resources Industrialization, National and Local Collaborative Engineering Center of Chinese Medicinal Resources Industrialization and Formulae Innovative Medicine, Nanjing University of Chinese Medicine, Nanjing, China
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13
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Thango NS, Rohlwink UK, Dlamini L, Tshavhungwe MP, Banderker E, Salie S, Enslin JMN, Figaji AA. Brain interstitial glycerol correlates with evolving brain injury in paediatric traumatic brain injury. Childs Nerv Syst 2021; 37:1713-1721. [PMID: 33585956 DOI: 10.1007/s00381-021-05058-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/01/2020] [Accepted: 01/22/2021] [Indexed: 10/22/2022]
Abstract
PURPOSE A better understanding of the complex pathophysiology of traumatic brain injury (TBI) is needed to improve our current therapies. Cerebral microdialysis (CMD) is an advanced method to monitor the brain, but little is known about its parameters in children. Brain glycerol, one of the CMD variables, is an essential component of the phospholipid bilayer cell membrane and is considered a useful marker of tissue hypoxia in adults. This study examined the time course of glycerol and its associations in paediatric TBI. METHODS In this retrospective cohort study, we collected data on children (< 13years) with severe TBI who underwent CMD monitoring. The relationship of glycerol was examined with respect to physiological, radiological variables, and clinical outcome. RESULTS Twenty-eight children underwent CMD monitoring and had evaluable data. Lesion progression on head computed tomography (CT) demonstrated a strong relationship with glycerol (median glycerol, maximum and initial-to-maximum) when lesion size increased by > 30% (p=0.01, p=0.04 and p=0.004). Absolute glycerol values had a weak but statistically significant association with intracranial pressure and brain oxygenation. We did not find an association with clinical outcome. CONCLUSION This is the first study to provide data on brain interstitial glycerol in children. CMD glycerol, particularly an increase from baseline, is associated with other markers of injury and with a significant increase in lesion size on repeat head CT. As such, it may represent a useful monitorable marker for evolving injury in paediatric TBI.
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Affiliation(s)
- Nqobile S Thango
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Ursula K Rohlwink
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa.,Neuroscience Institute, University of Cape Town, Cape Town, South Africa
| | - Lindizwe Dlamini
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - M Phophi Tshavhungwe
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - E Banderker
- Department of Radiology, University of Cape Town, Cape Town, South Africa
| | - Shamiel Salie
- Paediatric Intensive Care Unit, Red Cross War Memorial Children's Hospital, University of Cape Town, Cape Town, South Africa
| | - J M N Enslin
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa
| | - Anthony A Figaji
- Division of Neurosurgery, Department of Surgery, University of Cape Town, Cape Town, South Africa. .,Neuroscience Institute, University of Cape Town, Cape Town, South Africa.
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14
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Simoniuk UD, Haunschild J, von Aspern K, Boschmann M, Klug L, Khachatryan Z, Bianchi E, Ossmann S, Oo AY, Borger MA, Etz CD. Near real-time bedside detection of spinal cord ischaemia during aortic repair by microdialysis of the cerebrospinal fluid. Eur J Cardiothorac Surg 2020; 58:629-637. [PMID: 32359065 DOI: 10.1093/ejcts/ezaa124] [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: 09/02/2019] [Revised: 01/11/2020] [Accepted: 02/04/2020] [Indexed: 11/12/2022] Open
Abstract
OBJECTIVES Spinal cord ischaemia (SCI) remains the most devastating complication after thoraco-abdominal aortic aneurysm (TAAA) repair. Its early detection is crucial if therapeutic interventions are to be successful. Cerebrospinal fluid (CSF) is readily available and accessible to microdialysis (MD) capable of detecting metabolites involved in SCI [i.e. lactate, pyruvate, the lactate/pyruvate ratio (LPR), glucose and glycerol] in real time. Our aim was to evaluate the feasibility of CSF MD for the real-time detection of SCI metabolites. METHODS In a combined experimental and translational approach, CSF MD was evaluated (i) in an established experimental large animal model of SCI with 2 arms: (a) after aortic cross-clamping (AXC, N = 4), simulating open TAAA repair and (b) after total segmental artery sacrifice (Th4-L5, N = 8) simulating thoracic endovascular aortic repair. The CSF was analysed utilizing MD every 15 min. Additionally, CSF was collected hourly from 6 patients undergoing open TAAA repair in a high-volume aortic reference centre and analysed using CSF MD. RESULTS In the experimental AXC group, CSF lactate increased 3-fold after 10 min and 10-fold after 60 min of SCI. Analogously, the LPR increased 5-fold by the end of the main AXC period. Average glucose levels demonstrated a 1.5-fold increase at the end of the first (preconditioning) AXC period (0.60±0.14 vs 0.97±0.32 mmol/l); however, they decreased below (to 1/3 of) baseline levels (0.60±0.14 vs 0.19±0.13 mmol/l) by the end of the experiment (after simulated distal arrest). In the experimental segmental artery sacrifice group, lactate levels doubled and the LPR increased 3.3-fold within 30 min and continued to increase steadily almost 5-fold 180 min after total segmental artery sacrifice (P < 0.05). In patients undergoing TAAA repair, lactate similarly increased 5-fold during ischaemia, reaching a maximum at 6 h postoperatively. In 2 patients with intraoperative SCI, indicated by a decrease in the motor evoked potential of >50%, the LPR increased by 200%. CONCLUSIONS CSF is widely available during and after TAAA repair, and CSF MD is feasible for detection of early anaerobic metabolites of SCI. CSF MD is a promising new tool combining bedside availability and real-time capacity to potentially enable rapid detection of imminent SCI, thereby maximizing chances to prevent permanent paraplegia in patients with TAAA.
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Affiliation(s)
- Urszula D Simoniuk
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.,Saxon Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany.,Department of Cardiothoracic Surgery, Barts Heart Centre, London, UK
| | - Josephina Haunschild
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.,Saxon Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Konstantin von Aspern
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.,Saxon Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Michael Boschmann
- Experimental & Clinical Research Center, a joint co-operation between Charité Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Lars Klug
- Experimental & Clinical Research Center, a joint co-operation between Charité Universitätsmedizin Berlin and Max Delbrück Center for Molecular Medicine, Berlin, Germany
| | - Zara Khachatryan
- Saxon Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
| | - Edoardo Bianchi
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Susann Ossmann
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Aung Y Oo
- Department of Cardiothoracic Surgery, Barts Heart Centre, London, UK
| | - Michael A Borger
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany
| | - Christian D Etz
- University Department of Cardiac Surgery, Heart Centre Leipzig, Leipzig, Germany.,Saxon Incubator for Clinical Translation (SIKT), University Leipzig, Leipzig, Germany
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15
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Slavoaca D, Muresanu D, Birle C, Rosu OV, Chirila I, Dobra I, Jemna N, Strilciuc S, Vos P. Biomarkers in traumatic brain injury: new concepts. Neurol Sci 2020; 41:2033-2044. [PMID: 32157587 DOI: 10.1007/s10072-019-04238-y] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/20/2019] [Accepted: 12/30/2019] [Indexed: 12/21/2022]
Abstract
Traumatic brain injury is a multifaceted condition that encompasses a spectrum of injuries: contusions, axonal injuries in specific brain regions, edema, and hemorrhage. Brain injury determines a broad clinical and disability spectrum due to the implication of various cellular pathways, genetic phenotypes, and environmental factors. It is challenging to predict patient outcomes, to appropriately evaluate the patients, to determine a suitable treatment strategy and rehabilitation program, and to communicate with patient relatives. Biomarkers detected from body fluids are potential evaluation tools for traumatic brain injury patients. These may serve as internal indicators of cerebral damage, delivering valuable information about the dynamic cellular, biochemical, and molecular environments. The diagnostic and prognostic value of biomarkers tested both in animal models of traumatic brain injury is still under question, despite a considerable scientific literature. Recent publications emphasize that a more realistic approach involves combining multiple types of biomarkers with other investigative tools (imaging, outcome scales, and genetic polymorphisms). Additionally, there is increasing interest in the use of biomarkers as tools for treatment monitoring and as surrogate outcome variables to facilitate the design of distinct randomized controlled trials. This review highlights the latest available evidence regarding biomarkers in adults after traumatic brain injury and discusses new approaches in the evaluation of this patient group.
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Affiliation(s)
- Dana Slavoaca
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Dafin Muresanu
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania.
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania.
| | - Codruta Birle
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Olivia Verisezan Rosu
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Ioana Chirila
- Neurology Clinic, Cluj Emergency County Hospital, Cluj-Napoca, Romania
| | - Iulia Dobra
- Neurology Clinic, Cluj Emergency County Hospital, Cluj-Napoca, Romania
| | - Nicoleta Jemna
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Stefan Strilciuc
- Department of Neurosciences, "Iuliu Hatieganu" University of Medicine and Pharmacy, Cluj-Napoca, Romania
- RoNeuro Institute for Neurological Research and Diagnostic, No. 37 Mircea Eliade Street, 400486, Cluj-Napoca, Romania
| | - Pieter Vos
- Department of Neurology, Slingeland Hospital, Doetinchem, The Netherlands
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16
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Ruhatiya RS, Adukia SA, Manjunath RB, Maheshwarappa HM. Current Status and Recommendations in Multimodal Neuromonitoring. Indian J Crit Care Med 2020; 24:353-360. [PMID: 32728329 PMCID: PMC7358870 DOI: 10.5005/jp-journals-10071-23431] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
Abstract
Every patient in neurocritical care evolves through two phases. Acute pathologies are addressed first. These include trauma, hemorrhagic or ischemic stroke, or neuroinfection. Soon after, the concentration shifts to identifying secondary pathologies like fever, seizures, and ischemia, which may exacerbate the brain injury. Frequent bedside examinations are not sufficient for timely detection and prevention of secondary brain injury (SBI) as per the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care. Multimodality monitoring (MMM) can help in tailoring treatment decisions to prevent such a brain injury. Multimodal neuromonitoring involves data-guided therapeutic interventions by employing various tools and data integration to understand brain physiology. Monitors provide real-time information on cerebral hemodynamics, oxygenation, metabolism, and electrophysiology. The monitors may be invasive/noninvasive and global/regional. We have reviewed such technologies in this write-up. Novel themes like bioinformatics, clinical research, and device development will also be discussed.
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Affiliation(s)
- Radhika S Ruhatiya
- Department of Critical Care Medicine, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Sachin A Adukia
- Department of Neurology, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Ramya B Manjunath
- Department of Anesthesia, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
| | - Harish M Maheshwarappa
- Department of Critical Care Medicine, Narayana Hrudayalaya, NH Health City, Bengaluru, Karnataka, India
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17
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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18
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Nag DS, Sahu S, Swain A, Kant S. Intracranial pressure monitoring: Gold standard and recent innovations. World J Clin Cases 2019; 7:1535-1553. [PMID: 31367614 PMCID: PMC6658373 DOI: 10.12998/wjcc.v7.i13.1535] [Citation(s) in RCA: 90] [Impact Index Per Article: 18.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Shashi Kant
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
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19
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Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
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Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
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20
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Abstract
Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
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21
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Cerebrospinal fluid and brain extracellular fluid in severe brain trauma. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:237-258. [DOI: 10.1016/b978-0-12-804279-3.00014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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22
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Zeiler FA, Thelin EP, Helmy A, Czosnyka M, Hutchinson PJA, Menon DK. A systematic review of cerebral microdialysis and outcomes in TBI: relationships to patient functional outcome, neurophysiologic measures, and tissue outcome. Acta Neurochir (Wien) 2017; 159:2245-2273. [PMID: 28988334 PMCID: PMC5686263 DOI: 10.1007/s00701-017-3338-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/19/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To perform a systematic review on commonly measured cerebral microdialysis (CMD) analytes and their association to: (A) patient functional outcome, (B) neurophysiologic measures, and (C) tissue outcome; after moderate/severe TBI. The aim was to provide a foundation for next-generation CMD studies and build on existing pragmatic expert guidelines for CMD. METHODS We searched MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to October 2016). Strength of evidence was adjudicated using GRADE. RESULTS (A) Functional Outcome: 55 articles were included, assessing outcome as mortality or Glasgow Outcome Scale (GOS) at 3-6 months post-injury. Overall, there is GRADE C evidence to support an association between CMD glucose, glutamate, glycerol, lactate, and LPR to patient outcome at 3-6 months. (B) Neurophysiologic Measures: 59 articles were included. Overall, there currently exists GRADE C level of evidence supporting an association between elevated CMD measured mean LPR, glutamate and glycerol with elevated ICP and/or decreased CPP. In addition, there currently exists GRADE C evidence to support an association between elevated mean lactate:pyruvate ratio (LPR) and low PbtO2. Remaining CMD measures and physiologic outcomes displayed GRADE D or no evidence to support a relationship. (C) Tissue Outcome: four studies were included. Given the conflicting literature, the only conclusion that can be drawn is acute/subacute phase elevation of CMD measured LPR is associated with frontal lobe atrophy at 6 months. CONCLUSIONS This systematic review replicates previously documented relationships between CMD and various outcome, which have driven clinical application of the technique. Evidence assessments do not address the application of CMD for exploring pathophysiology or titrating therapy in individual patients, and do not account for the modulatory effect of therapy on outcome, triggered at different CMD thresholds in individual centers. Our findings support clinical application of CMD and refinement of existing guidelines.
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Affiliation(s)
- Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Department of Clinical Neuroscience, Neurosurgical Research Laboratory, Karolinska University Hospital, Building R2:02, Karolinska Institutet, S-17176 Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Section of Brain Physics, Division of Neurosurgery, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Peter J. A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - David K. Menon
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
- Queens’ College, Cambridge, UK
- National Institute for Health Research, Southampton, UK
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Lauritzen M, Strong AJ. 'Spreading depression of Leão' and its emerging relevance to acute brain injury in humans. J Cereb Blood Flow Metab 2017; 37:1553-1570. [PMID: 27354095 PMCID: PMC5435290 DOI: 10.1177/0271678x16657092] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
A new research field in translational neuroscience has opened as a result of the recognition since 2002 that "spreading depression of Leão" can be detected in many patients with acute brain injury, whether vascular and spontaneous, or traumatic in origin, as well as in those many individuals experiencing the visual (or sensorimotor) aura of migraine. In this review, we trace from their first description in rabbits through to their detection and study in migraine and the injured human brain, and from our personal perspectives, the evolution of understanding of the importance of spread of mass depolarisations in cerebral grey matter. Detection of spontaneous depolarisations occurring and spreading in the periphery or penumbra of experimental focal cortical ischemic lesions and of their adverse effects on the cerebral cortical microcirculation and on the tissue glucose and oxygen pools has led to clearer concepts of how ischaemic and traumatic lesions evolve in the injured human brain, and of how to seek to improve clinical management and outcome. Recognition of the likely fundamental significance of spreading depolarisations for this wide range of serious acute encephalopathies in humans provides a powerful case for a fresh examination of neuroprotection strategies.
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Affiliation(s)
- Martin Lauritzen
- 1 Department of Neuroscience and Pharmacology and Center for Healthy Aging, University of Copenhagen, Copenhagen, Denmark.,2 Department of Clinical Neurophysiology, Rigshospitalet, Glostrup, Denmark
| | - Anthony J Strong
- 3 Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King's College London, London, UK
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Abstract
The monitoring of systemic and central nervous system physiology is central to the management of patients with neurologic disease in the perioperative and critical care settings. There exists a range of invasive and noninvasive and global and regional monitors of cerebral hemodynamics, oxygenation, metabolism, and electrophysiology that can be used to guide treatment decisions after acute brain injury. With mounting evidence that a single neuromonitor cannot comprehensively detect all instances of cerebral compromise, multimodal neuromonitoring allows an individualized approach to patient management based on monitored physiologic variables rather than a generic one-size-fits-all approach targeting predetermined and often empirical thresholds.
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Vlodavsky E, Palzur E, Shehadeh M, Soustiel JF. Post-traumatic cytotoxic edema is directly related to mitochondrial function. J Cereb Blood Flow Metab 2017; 37:166-177. [PMID: 26672111 PMCID: PMC5363733 DOI: 10.1177/0271678x15621068] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/26/2015] [Accepted: 11/11/2015] [Indexed: 01/15/2023]
Abstract
Cerebral edema represents a major threat following traumatic brain injury. However, therapeutic measures for control of intracranial pressure alone have failed to restore cerebral metabolism and improve neurological outcome. Since mitochondrial damage results in ATP depletion and deactivation of membrane ionic pumps, we hypothesized that modulation of ATP bioavailability may directly affect cytotoxic edema. Intracranial pressure measurements were performed in Sprague-Dawley rats treated by intraperitoneal injection of dimethylsulfoxide (vehicle), cyclosporine A (CsA), or Oligomycin B (OligB) following cortical contusion and further correlated with water content, mitochondrial damage, and electron microscopic assessment of neuronal and axonal edema. As hypothesized, ultra-structural figures of edema closely correlated with intracranial pressure elevation, increased water content and mitochondrial membrane permeabilization expressed by loss of transmembrane mitochondrial potential. Further, mitochondrial damage evidenced ultra-structurally by figures of swollen mitochondria with severely distorted cristae correlated with both cytotoxic edema and mitochondrial dysfunction. Importantly, cerebral edema and mitochondrial impairment were significantly worsened by treatment with OligB, whereas a noticeable improvement could be observed in animals that received injections of CsA. Since OligB and CsA are responsible for symmetrical and opposite effects on oxidative metabolism, these findings support the hypothesis of a causative relationship between edema and mitochondrial function.
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Affiliation(s)
- Eugene Vlodavsky
- Institute of Pathology, Rambam Medical Center, Haifa, Israel.,The Ruth & Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Eilam Palzur
- Eliachar Research Laboratory, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel
| | - Mona Shehadeh
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Jean F Soustiel
- Eliachar Research Laboratory, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel .,Department of Neurosurgery, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel
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Abstract
Neurocritical care has two main objectives. Initially, the emphasis is on treatment of patients with acute damage to the central nervous system whether through infection, trauma, or hemorrhagic or ischemic stroke. Thereafter, attention shifts to the identification of secondary processes that may lead to further brain injury, including fever, seizures, and ischemia, among others. Multimodal monitoring is the concept of using various tools and data integration to understand brain physiology and guide therapeutic interventions to prevent secondary brain injury. This chapter will review the use of electroencephalography, intracranial pressure monitoring, brain tissue oxygenation, cerebral microdialysis and neurochemistry, near-infrared spectroscopy, and transcranial Doppler sonography as they relate to neuromonitoring in the critically ill. The concepts and design of each monitor, in addition to the patient population that may most benefit from each modality, will be discussed, along with the various tools that can be used together to guide individualized patient treatment options. Major clinical trials, observational studies, and their effect on clinical outcomes will be reviewed. The future of multimodal monitoring in the field of bioinformatics, clinical research, and device development will conclude the chapter.
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Affiliation(s)
- G Korbakis
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA
| | - P M Vespa
- Department of Neurosurgery, UCLA David Geffen School of Medicine, Los Angeles, CA, USA; Department of Neurology, UCLA David Geffen School of Medicine, Los Angeles, CA, USA.
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Das C, Wang G, Sun Q, Ledden B. Multiplexed and fully automated detection of metabolic biomarkers using microdialysis probe. SENSORS AND ACTUATORS. B, CHEMICAL 2017; 238:633-640. [PMID: 28090149 PMCID: PMC5224532 DOI: 10.1016/j.snb.2016.07.097] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/06/2023]
Abstract
We report here, the design and development of an automated near real-time continuous detection system for lactate, glutamate, pyruvate and glucose using microdialysis probe. The system developed can automatically push perfusate through microdialysis probe (20, 100 and 1000 kDa MWCO cutoff probe) at low to medium flow rate of 0.5-2 μL/min with almost 100% fluid recovery. The microdialysate collected from the probe is analyzed automatically for these four metabolite biomarkers. It operates in a continuous mode with measurements of all four biomarkers once every 20 min. The dynamic range for these different markers covers the entire clinical range of traumatic brain injury. The prototype shows a low variation of ~ 7-10% across the entire clinical range for all the biomarkers with fairly good accuracy of ~95%. The instrument canrun continuously for 24 h without user intervention. With a long tubing of 1 m to and from the microdialysis probe and associated dead volume, the total lag time for actual event at the probe site versusreported concentration is roughly 1 h.
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Kafaki SB, Alaedini K, Qorbani A, Asadian L, Haddadi K. Hyperglycemia: A Predictor of Death in Severe Head Injury Patients. CLINICAL MEDICINE INSIGHTS-ENDOCRINOLOGY AND DIABETES 2016; 9:43-46. [PMID: 27695379 PMCID: PMC5038612 DOI: 10.4137/cmed.s40330] [Citation(s) in RCA: 14] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2016] [Revised: 08/11/2016] [Accepted: 08/15/2016] [Indexed: 01/08/2023]
Abstract
OBJECTIVES Management of hyperglycemia during an acute sickness in adults is accompanied by improved outcomes. We have designed a prospective study with meticulous attention to exclude all diabetes patients by checking hemoglobin A1c (HbA1c or glycated hemoglobin) to avoid the ill-effects of hyperglycemia in patients with traumatic head injury admitted to the intensive care unit (ICU). METHODS This prospective study included adults with traumatic primary brain injury with a Glasgow coma score of ≤8 necessitating mechanical ventilation treated in the period 2012-2015. After screening 311 patients, 220 were included in the study. Both blood glucose and HbA1c levels of all the patients at admission, as well as blood glucose level after 72 hours, were obtained from the records. The patients were later grouped based on their admission blood glucose levels (<200 mg/dL or ≥200 mg/dL). Injury severity score (ISS) was documented for every patient. As a final point, the outcomes were determined based on the hospital length of stay (HLS) and ICU length of stay (ILS), plusmortality rates. RESULTS About 39% (n = 85) of patients were admitted with hyperglycemia during the study period. The mortality rate in patients with glucose ≥200 mg/dL was 65.8% (N = 56), against 23.7% (N = 32) in the group with glucose <200 mg/dL, with mortality rising as the blood glucose level increased (P = 0.014). CONCLUSIONS We conclude that admission hyperglycemia is related with increased mortality rate in head injury patients, and comprehensive treatment of hyperglycemia can improve the outcome of severe head injury patients.
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Affiliation(s)
| | | | - Ashkan Qorbani
- MD, School of Medicine, Mazandaran University of Medical Science, Sari, Iran
| | | | - Kaveh Haddadi
- Associated Professor, Department of Neurosurgery, Diabetes Research Center, Emam Hospital, Diabetes Research Center, Mazandaran University of Medical Science, Sari, Iran
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Abstract
Microdialysis enables the chemistry of the extracellular interstitial space to be monitored. Use of this technique in patients with acute brain injury has increased our understanding of the pathophysiology of several acute neurological disorders. In 2004, a consensus document on the clinical application of cerebral microdialysis was published. Since then, there have been significant advances in the clinical use of microdialysis in neurocritical care. The objective of this review is to report on the International Microdialysis Forum held in Cambridge, UK, in April 2014 and to produce a revised and updated consensus statement about its clinical use including technique, data interpretation, relationship with outcome, role in guiding therapy in neurocritical care and research applications.
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Young B, Kalanuria A, Kumar M, Burke K, Balu R, Amendolia O, McNulty K, Marion B, Beckmann B, Ciocco L, Miller K, Schuele D, Maloney-Wilensky E, Frangos S, Wright D. Cerebral Microdialysis. Crit Care Nurs Clin North Am 2016; 28:109-24. [DOI: 10.1016/j.cnc.2015.09.005] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
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Amorini AM, Lazzarino G, Di Pietro V, Signoretti S, Lazzarino G, Belli A, Tavazzi B. Metabolic, enzymatic and gene involvement in cerebral glucose dysmetabolism after traumatic brain injury. Biochim Biophys Acta Mol Basis Dis 2016; 1862:679-687. [PMID: 26844378 DOI: 10.1016/j.bbadis.2016.01.023] [Citation(s) in RCA: 43] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2015] [Accepted: 01/29/2016] [Indexed: 12/16/2022]
Abstract
In this study, the metabolic, enzymatic and gene changes causing cerebral glucose dysmetabolism following graded diffuse traumatic brain injury (TBI) were evaluated. TBI was induced in rats by dropping 450g from 1 (mild TBI; mTBI) or 2m height (severe TBI; sTBI). After 6, 12, 24, 48, and 120h gene expressions and enzymatic activities of glycolysis and pentose phosphate pathway (PPP) enzymes, and levels of lactate, ATP, ADP, ATP/ADP (indexing mitochondrial phosphorylating capacity), NADP(+), NADPH and GSH were determined in whole brain extracts (n=9 rats at each time for both TBI levels). Sham-operated animals (n=9) were used as controls. Results demonstrated that mTBI caused a late increase (48-120h post injury) of glycolytic gene expression and enzymatic activities, concomitantly with mitochondrial functional recovery (ATP and ATP/ADP normalization). No changes in lactate and PPP genes and enzymes, were accompanied by transient decrease in GSH, NADP(+), NADPH and NADPH/NADP(+). Animals following sTBI showed early increase (6-24h post injury) of glycolytic gene expression and enzymatic activities, occurring during mitochondrial malfunctioning (50% decrease in ATP and ATP/ADP). Higher lactate and lower GSH, NADP(+), NADPH, NADPH/NADP(+) than controls were recorded at anytime post injury (p<0.01). Both TBI levels caused metabolic and gene changes affecting glucose metabolism. Following mTBI, increased glucose flux through glycolysis is coupled to mitochondrial glucose oxidation. "True" hyperglycolysis occurs only after sTBI, where metabolic changes, caused by depressed mitochondrial phosphorylating capacity, act on genes causing net glycolytic flux increase uncoupled from mitochondrial glucose oxidation.
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Affiliation(s)
- Angela Maria Amorini
- Institute of Biochemistry and Clinical Biochemistry, Catholic University of Rome, Largo F. Vito 1, 00168 Rome, Italy.
| | - Giacomo Lazzarino
- Institute of Biochemistry and Clinical Biochemistry, Catholic University of Rome, Largo F. Vito 1, 00168 Rome, Italy.
| | - Valentina Di Pietro
- Neurobiology, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, B15 2TT Birmingham, UK.
| | - Stefano Signoretti
- Division of Neurosurgery, Department of Neurosciences Head and Neck Surgery, S. Camillo Hospital, Circonvallazione Gianicolense 87, 00152 Rome, Italy.
| | - Giuseppe Lazzarino
- Department of Biomedical and Biotechnological Sciences, Division of Medical Biochemistry, University of Catania, Viale A. Doria 6, 95125 Catania, Italy.
| | - Antonio Belli
- Neurobiology, School of Clinical and Experimental Medicine, College of Medical and Dental Sciences, University of Birmingham, Edgbaston, B15 2TT Birmingham, UK; National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, Queen Elizabeth Hospital, Edgbaston, B15 2TH Birmingham, UK.
| | - Barbara Tavazzi
- Institute of Biochemistry and Clinical Biochemistry, Catholic University of Rome, Largo F. Vito 1, 00168 Rome, Italy.
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Advances in Intracranial Pressure Monitoring and Its Significance in Managing Traumatic Brain Injury. Int J Mol Sci 2015; 16:28979-97. [PMID: 26690122 PMCID: PMC4691093 DOI: 10.3390/ijms161226146] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 12/11/2022] Open
Abstract
Intracranial pressure (ICP) measurements are essential in evaluation and treatment of neurological disorders such as subarachnoid and intracerebral hemorrhage, ischemic stroke, hydrocephalus, meningitis/encephalitis, and traumatic brain injury (TBI). The techniques of ICP monitoring have evolved from invasive to non-invasive-with both limitations and advantages. Some limitations of the invasive methods include short-term monitoring, risk of infection, restricted mobility of the subject, etc. The invasiveness of a method limits the frequency of ICP evaluation in neurological conditions like hydrocephalus, thus hampering the long-term care of patients with compromised ICP. Thus, there has been substantial interest in developing noninvasive techniques for assessment of ICP. Several approaches were reported, although none seem to provide a complete solution due to inaccuracy. ICP measurements are fundamental for immediate care of TBI patients in the acute stages of severe TBI injury. In severe TBI, elevated ICP is associated with mortality or poor clinical outcome. ICP monitoring in conjunction with other neurological monitoring can aid in understanding the pathophysiology of brain damage. This review article presents: (a) the significance of ICP monitoring; (b) ICP monitoring methods (invasive and non-invasive); and (c) the role of ICP monitoring in the management of brain damage, especially TBI.
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International multidisciplinary consensus conference on multimodality monitoring: cerebral metabolism. Neurocrit Care 2015; 21 Suppl 2:S148-58. [PMID: 25208673 DOI: 10.1007/s12028-014-0035-3] [Citation(s) in RCA: 29] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Microdialysis is a powerful technique, which enables the chemistry of the extracellular space to be measured directly. Applying this technique to patients in neurointensive care has increased our understanding of the pathophysiology of traumatic brain injury and spontaneous hemorrhage. In parallel, it is important to determine the place of microdialysis in assisting in the management of patients on an individual intention to treat basis. This is made possible by the availability of analyzers which can measure the concentration of glucose, pyruvate, lactate, and glutamate at the bedside. Samples can then be stored for later analysis of other substrate and metabolites e.g., other amino acids and cytokines. The objective of this paper is to review the fundamental literature pertinent to the clinical application of microdialysis in neurointensive care and to give recommendations on how the technique can be applied to assist in patient management and contribute to outcome. A literature search detected 1,933 publications of which 55 were used for data abstraction and analysis. The role of microdialysis was evaluated in three conditions (traumatic brain injury, subarachnoid hemorrhage, and intracerebral hemorrhage) and recommendations focused on three fundamental areas (relationship to outcome, application of microdialysis to guide therapy, and the ability of microdialysis to predict secondary deterioration).
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Chesnut R, Videtta W, Vespa P, Le Roux P. Intracranial pressure monitoring: fundamental considerations and rationale for monitoring. Neurocrit Care 2015; 21 Suppl 2:S64-84. [PMID: 25208680 DOI: 10.1007/s12028-014-0048-y] [Citation(s) in RCA: 84] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Traumatic brain injury (TBI) is a major cause of death and disability worldwide. In large part critical care for TBI is focused on the identification and management of secondary brain injury. This requires effective neuromonitoring that traditionally has centered on intracranial pressure (ICP). The purpose of this paper is to review the fundamental literature relative to the clinical application of ICP monitoring in TBI critical care and to provide recommendations on how the technique maybe applied to help patient management and enhance outcome. A PubMed search between 1980 and September 2013 identified 2,253 articles; 244 of which were reviewed in detail to prepare this report and the evidentiary tables. Several important concepts emerge from this review. ICP monitoring is safe and is best performed using a parenchymal monitor or ventricular catheter. While the indications for ICP monitoring are well established, there remains great variability in its use. Increased ICP, particularly the pattern of the increase and ICP refractory to treatment is associated with increased mortality. Class I evidence is lacking on how monitoring and management of ICP influences outcome. However, a large body of observational data suggests that ICP management has the potential to influence outcome, particularly when care is targeted and individualized and supplemented with data from other monitors including the clinical examination and imaging.
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Affiliation(s)
- Randall Chesnut
- Brain and Spine Center, Suite 370, Medical Science Building, Lankenau Medical Center, 100 East Lancaster Avenue, Wynnewood, PA, 19096, USA
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Nouveaux outils de neuromonitorage. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1099-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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Tan TK, Cheng MH, Sim EY. Options for managing raised intracranial pressure. PROCEEDINGS OF SINGAPORE HEALTHCARE 2015. [DOI: 10.1177/2010105815598444] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Abstract
This article reviews the current monitoring and management options for raised intracranial pressure (ICP), primarily in traumatic head injuries, in line with current literature and guidelines. The use of ICP monitoring is useful in managing, predicting outcomes, following the progression and guiding interventions of neurological disease states. Patients with raised ICP should be monitored closely in a neurocritical care setting where appropriate interventions can be instituted based on available monitoring parameters. Various first- and second-tier methods should be considered, with the primary goal to decrease secondary insult to brain tissue for best outcomes.
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Affiliation(s)
- Tong Khee Tan
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Ming Hua Cheng
- Department of Anaesthesiology, Singapore General Hospital, Singapore
| | - Eileen Yilin Sim
- Department of Anaesthesiology, Singapore General Hospital, Singapore
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Abstract
The mass transport or flux of neurochemicals in the brain and how this flux affects chemical measurements and their interpretation is reviewed. For all endogenous neurochemicals found in the brain, the flux of each of these neurochemicals exists between sources that produce them and the sites that consume them all within μm distances. Principles of convective-diffusion are reviewed with a significant emphasis on the tortuous paths and discrete point sources and sinks. The fundamentals of the primary methods of detection, microelectrodes and microdialysis sampling of brain neurochemicals are included in the review. Special attention is paid to the change in the natural flux of the neurochemicals caused by implantation and consumption at microelectrodes and uptake by microdialysis. The detection of oxygen, nitric oxide, glucose, lactate, and glutamate, and catecholamines by both methods are examined and where possible the two techniques (electrochemical vs. microdialysis) are compared. Non-invasive imaging methods: magnetic resonance, isotopic fluorine MRI, electron paramagnetic resonance, and positron emission tomography are also used for different measurements of the above-mentioned solutes and these are briefly reviewed. Although more sophisticated, the imaging techniques are unable to track neurochemical flux on short time scales, and lack spatial resolution. Where possible, determinations of flux using imaging are compared to the more classical techniques of microdialysis and microelectrodes.
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Affiliation(s)
- David W Paul
- Department of Chemistry and Biochemistry, University of Arkansas, Fayetteville, AR 72701, USA.
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Sheriff FG, Hinson HE. Pathophysiology and clinical management of moderate and severe traumatic brain injury in the ICU. Semin Neurol 2015; 35:42-9. [PMID: 25714866 DOI: 10.1055/s-0035-1544238] [Citation(s) in RCA: 36] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
Moderate and severe traumatic brain injury (TBI) is the leading cause of morbidity and mortality among young individuals in high-income countries. Its pathophysiology is divided into two major phases: the initial neuronal injury (or primary injury) followed by secondary insults (secondary injury). Multimodality monitoring now offers neurointensivists the ability to monitor multiple physiologic parameters that act as surrogates of brain ischemia and hypoxia, the major driving forces behind secondary brain injury. The heterogeneity of the pathophysiology of TBI makes it necessary to take into consideration these interacting physiologic factors when recommending for or against any therapies; it may also account for the failure of all the neuroprotective therapies studied so far. In this review, the authors focus on neuroclinicians and neurointensivists, and discuss the developments in therapeutic strategies aimed at optimizing intracranial pressure and cerebral perfusion pressure, and minimizing cerebral hypoxia. The management of moderate to severe TBI in the intensive care unit is moving away from a pure "threshold-based" treatment approach toward consideration of patient-specific characteristics, including the state of cerebral autoregulation. The authors also include a concise discussion on the management of medical and neurologic complications peculiar to TBI as well as an overview of prognostication.
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Affiliation(s)
- Faheem G Sheriff
- Department of Neurology, Oregon Health Science University, Portland, Oregon
| | - Holly E Hinson
- Department of Neurology, Oregon Health Science University, Portland, Oregon
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Abstract
PURPOSE OF REVIEW Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI), but whether its management improves the outcome is unclear. In this review, we will examine the implications of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) trial, evidence for an influence of ICP care on outcome, and a need for greater understanding of the pathophysiology than just ICP through multimodal monitoring (MMM) to enhance the outcome. RECENT FINDINGS The primary impact of the BEST TRIP trial, a randomized clinical trial that examined two TBI management strategies, one that used an ICP monitor, is in research and should not alter clinical practice. Analyses of large databases suggest TBI care based on the Brain Trauma Foundation guidelines and management of intracranial hypertension can improve patient outcome. However, accumulating evidence demonstrates there are several mechanisms of secondary brain injury (SBI), for example, microvascular dysfunction or alterations in glucose utilization that cannot be detected using an ICP monitor. In these patients, growing clinical evidence suggests that MMM can help manage SBI and improve TBI outcome. SUMMARY ICP-based monitoring and treatment alone may not be enough to enhance TBI outcome, but ICP and cerebral perfusion pressure therapy remain important in TBI care. Although high-quality evidence for MMM is limited, it should be more widely adapted to better understand the complex pathophysiology after TBI, better target care, and identify new therapeutic opportunities.
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Prabhakar H, Sandhu K, Bhagat H, Durga P, Chawla R. Current concepts of optimal cerebral perfusion pressure in traumatic brain injury. J Anaesthesiol Clin Pharmacol 2014; 30:318-27. [PMID: 25190937 PMCID: PMC4152669 DOI: 10.4103/0970-9185.137260] [Citation(s) in RCA: 47] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/03/2022] Open
Abstract
Traumatic brain injury (TBI) consists of varied pathophysiological consequences and alteration of intracranial dynamics, reduction of the cerebral blood flow and oxygenation. In the past decade more emphasis has been directed towards optimizing cerebral perfusion pressure (CPP) in patients who have suffered TBI. Injured brain may show signs of ischemia if CPP remains below 50 mmHg and raising the CPP above 60 mmHg may avoid cerebral oxygen desaturation. Though CPP above 70 mmHg is influential in achieving an improved patient outcome, maintenance of CPP higher than 70 mmHg was associated with greater risk of acute respiratory distress syndrome (ARDS). The target CPP has been laid within 50-70 mmHg. Cerebral blood flow and metabolism are heterogeneous after TBI and with regional temporal differences in the requirement for CPP. Brain monitoring techniques such as jugular venous oximetry, monitoring of brain tissue oxygen tension (PbrO2), and cerebral microdialysis provide complementary and specific information that permits the selection of the optimal CPP. This review highlights the rationale for use CPP directed therapies and neuromonitoring to identify optimal CPP of head injured patients. The article also reviews the evidence provided by various clinical trials regarding optimal CPP and their application in the management of head injured patients.
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Affiliation(s)
- Hemanshu Prabhakar
- Department of Neuroanaesthesiology, Neurosciences Centre, All India Institute of Medical Sciences, PGIMER, Chandigarh, India
| | - Kavita Sandhu
- Department of Neuroanaesthesiology and Critical Care, Max Superspeciality Hospital, PGIMER, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, PGIMER, Chandigarh, India
| | - Padmaja Durga
- Department of Anesthesiology and Intensive Care, Nizam's Institute of Medical Sciences, Hyderabad, India
| | - Rajiv Chawla
- Department of Anaesthesiology and Intensive Care, G B Pant Hospital, New Delhi, India
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Kurtz P, Claassen J, Helbok R, Schmidt J, Fernandez L, Presciutti M, Stuart RM, Connolly ES, Lee K, Badjatia N, Mayer SA. Systemic glucose variability predicts cerebral metabolic distress and mortality after subarachnoid hemorrhage: a retrospective observational study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2014; 18:R89. [PMID: 24887049 PMCID: PMC4056693 DOI: 10.1186/cc13857] [Citation(s) in RCA: 48] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/18/2013] [Accepted: 04/24/2014] [Indexed: 01/04/2023]
Abstract
Introduction Cerebral glucose metabolism and energy production are affected by serum glucose levels. Systemic glucose variability has been shown to be associated with poor outcome in critically ill patients. The objective of this study was to assess whether glucose variability is associated with cerebral metabolic distress and outcome after subarachnoid hemorrhage. Methods A total of 28 consecutive comatose patients with subarachnoid hemorrhage, who underwent cerebral microdialysis and intracranial pressure monitoring, were studied. Metabolic distress was defined as lactate/pyruvate ratio (LPR) >40. The relationship between daily glucose variability, the development of cerebral metabolic distress and hospital outcome was analyzed using a multivariable general linear model with a logistic link function for dichotomized outcomes. Results Daily serum glucose variability was expressed as the standard deviation (SD) of all serum glucose measurements. General linear models were used to relate this predictor variable to cerebral metabolic distress and mortality at hospital discharge. A total of 3,139 neuromonitoring hours and 181 days were analyzed. After adjustment for Glasgow Coma Scale (GCS) scores and brain glucose, SD was independently associated with higher risk of cerebral metabolic distress (adjusted odds ratio = 1.5 (1.1 to 2.1), P = 0.02). Increased variability was also independently associated with in hospital mortality after adjusting for age, Hunt Hess, daily GCS and symptomatic vasospasm (P = 0.03). Conclusions Increased systemic glucose variability is associated with cerebral metabolic distress and increased hospital mortality. Therapeutic approaches that reduce glucose variability may impact on brain metabolism and outcome after subarachnoid hemorrhage.
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Bothe MK, Stover JF. Monitoring of acute traumatic brain injury in adults to prevent secondary brain damage. FUTURE NEUROLOGY 2014. [DOI: 10.2217/fnl.13.78] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022]
Abstract
ABSTRACT: Traumatic brain injury is typically characterized by the primary injury initiating a cascade of pathologic changes that then lead to secondary brain injury. Secondary brain injury is amenable to different therapeutic options. Monitoring of otherwise occult pathologic changes involving oxygenation and metabolism is crucial for treatment decisions. Currently, decision-making is mainly based on measuring intracranial pressure and cerebral perfusion pressure. Importantly, extending neuromonitoring by including parameters reflecting cerebral perfusion, oxygenation and metabolism may improve treatment of traumatic brain injury patients by detecting neuronal damage despite optimal intracranial pressure or cerebral perfusion pressure and preventing unnecessarily aggressive treatment potentially causing local and systemic harm. In this review, the authors describe the advantages and disadvantages of contemporary, extended neuromonitoring methods in traumatic brain injury patients aimed at unmasking secondary brain damage as early as possible.
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Affiliation(s)
- Melanie K Bothe
- Fresenius Kabi Deutschland GmbH, Rathausplatz 3, 61348 Bad Homburg, Germany
| | - John F Stover
- Fresenius Kabi Deutschland GmbH, Rathausplatz 3, 61348 Bad Homburg, Germany
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Ragauskas A, Bartusis L, Piper I, Zakelis R, Matijosaitis V, Petrikonis K, Rastenyte D. Improved diagnostic value of a TCD-based non-invasive ICP measurement method compared with the sonographic ONSD method for detecting elevated intracranial pressure. Neurol Res 2014; 36:607-14. [DOI: 10.1179/1743132813y.0000000308] [Citation(s) in RCA: 49] [Impact Index Per Article: 4.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
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45
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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.
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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
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46
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Ali A, Konakondla S, Zwagerman NT, Peng C, Schafer S, Ding JY, Dornbos D, Sikharam C, Geng X, Guthikonda M, Kreipke CW, Rafols JA, Ding Y. Glycerol accumulation in edema formation following diffuse traumatic brain injury. Neurol Res 2013; 34:462-8. [DOI: 10.1179/1743132812y.0000000014] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023]
Affiliation(s)
- Ahmer Ali
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Sanjay Konakondla
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Nathan T Zwagerman
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
- Department of Neurological SurgeryUniversity of Pittsburgh Medical Center, Pittsuburgh, PA, USA
| | - Changya Peng
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Steven Schafer
- Anatomy and Cell BiologyWayne State University, School of Medicine, Detroit, MI, USA
| | | | - David Dornbos
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Chaitanya Sikharam
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Xiaokun Geng
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Murali Guthikonda
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
| | - Christian W Kreipke
- Anatomy and Cell BiologyWayne State University, School of Medicine, Detroit, MI, USA
| | - José A Rafols
- Anatomy and Cell BiologyWayne State University, School of Medicine, Detroit, MI, USA
| | - Yuchuan Ding
- Neurological Surgery; Wayne State UniversitySchool of Medicine, Detroit, MI, USA
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47
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Reduced Brain/Serum Glucose Ratios Predict Cerebral Metabolic Distress and Mortality After Severe Brain Injury. Neurocrit Care 2013; 19:311-9. [DOI: 10.1007/s12028-013-9919-x] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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48
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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.
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Affiliation(s)
- Peter Le Roux
- Department of Neurosurgery, University of Pennsylvania, 235 South 8th Street, Philadelphia, PA 19106, USA.
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49
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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.
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Affiliation(s)
- Peter D Le Roux
- The Brain and Spine Center, Lankenau Medical Center, 100 E. Lancaster Ave, Wynnewood, PA 19096, USA.
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50
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Frattalone AR, Ling GSF. Moderate and severe traumatic brain injury: pathophysiology and management. Neurosurg Clin N Am 2013; 24:309-19. [PMID: 23809027 DOI: 10.1016/j.nec.2013.03.006] [Citation(s) in RCA: 34] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Abstract
Traumatic brain injury (TBI) is a serious disorder that is all too common. TBI ranges in severity from mild concussion to a severe life-threatening state. Across this spectrum, rational therapeutic approaches exist. Early identification that TBI has occurred in a patient is paramount to optimal outcome. Proper clinical management should be instituted as soon as possible by appropriately trained medical providers. More seriously injured patients must be triaged to advanced care centers. It is only through this rational approach to TBI that patients may expect to achieve optimal clinical and functional outcome.
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Affiliation(s)
- Anthony R Frattalone
- Division of Neurocritical Care, Department of Anesthesiology and Critical Care Medicine, Johns Hopkins Medical Institutions, 600 N. Wolfe St, Baltimore, MD 21287, USA
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