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Wang Q, Pan M, Kreiss L, Samaei S, Carp SA, Johansson JD, Zhang Y, Wu M, Horstmeyer R, Diop M, Li DDU. A comprehensive overview of diffuse correlation spectroscopy: Theoretical framework, recent advances in hardware, analysis, and applications. Neuroimage 2024; 298:120793. [PMID: 39153520 DOI: 10.1016/j.neuroimage.2024.120793] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2024] [Revised: 07/23/2024] [Accepted: 08/14/2024] [Indexed: 08/19/2024] Open
Abstract
Diffuse correlation spectroscopy (DCS) is a powerful tool for assessing microvascular hemodynamic in deep tissues. Recent advances in sensors, lasers, and deep learning have further boosted the development of new DCS methods. However, newcomers might feel overwhelmed, not only by the already-complex DCS theoretical framework but also by the broad range of component options and system architectures. To facilitate new entry to this exciting field, we present a comprehensive review of DCS hardware architectures (continuous-wave, frequency-domain, and time-domain) and summarize corresponding theoretical models. Further, we discuss new applications of highly integrated silicon single-photon avalanche diode (SPAD) sensors in DCS, compare SPADs with existing sensors, and review other components (lasers, sensors, and correlators), as well as data analysis tools, including deep learning. Potential applications in medical diagnosis are discussed and an outlook for the future directions is provided, to offer effective guidance to embark on DCS research.
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Affiliation(s)
- Quan Wang
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Mingliang Pan
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Lucas Kreiss
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Saeed Samaei
- Department of Medical and Biophysics, Schulich School of Medical & Dentistry, Western University, London, Ontario, Canada; Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
| | - Stefan A Carp
- Massachusetts General Hospital, Optics at Athinoula A. Martinos Center for Biomedical Imaging, Harvard Medical School, Charlestown, MA, United States
| | | | - Yuanzhe Zhang
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, United Kingdom
| | - Melissa Wu
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Roarke Horstmeyer
- Department of Biomedical Engineering, Duke University, Durham, NC, United States
| | - Mamadou Diop
- Department of Medical and Biophysics, Schulich School of Medical & Dentistry, Western University, London, Ontario, Canada; Lawson Health Research Institute, Imaging Program, London, Ontario, Canada
| | - David Day-Uei Li
- Department of Biomedical Engineering, Faculty of Engineering, University of Strathclyde, Glasgow, United Kingdom.
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Malinova V, Kranawetter B, Tuzi S, Moerer O, Rohde V, Mielke D. Interaction of Optimal Cerebral Perfusion Pressure with Early Brain Injury and its Impact on Ischemic Complications and Outcome Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:879-885. [PMID: 37726549 PMCID: PMC11147945 DOI: 10.1007/s12028-023-01822-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/27/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Cerebral autoregulation is impaired early on after aneurysmal subarachnoid hemorrhage (aSAH). The study objective was to explore the pressure reactivity index (PRx) and cerebral perfusion pressure (CPP) in the earliest phase after aneurysm rupture and to address the question of whether an optimal CPP (CPPopt)-targeted management is associated with less severe early brain injury (EBI). METHODS Patients with aSAH admitted between 2012 and 2020 were retrospectively included in this observational cohort study. The PRx was calculated as a correlation coefficient between intracranial pressure and mean arterial pressure. By plotting the PRx versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. EBI was assessed by applying the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) on day 3 after ictus. An SEBES ≥ 3 was considered severe EBI. RESULTS In 90 of 324 consecutive patients with aSAH, intracranial pressure monitoring was performed ≥ 7 days, allowing for PRx calculation and CPPopt determination. Severe EBI was associated with larger mean deviation of CPP from CPPopt 72 h after ictus (r = 0.22, p = 0.03). Progressive edema requiring decompressive hemicraniectomy was associated with larger deviation of CPP from CPPopt on day 2 (r = 0.23, p = 0.02). The higher the difference of CPP from CPPopt on day 3 the higher the mortality rate (r = 0.31, p = 0.04). CONCLUSIONS Patients with CPP near to the calculated CPPopt in the early phase after aSAH experienced less severe EBI, less frequently received decompressive hemicraniectomy, and exhibited a lower mortality rate. A prospective evaluation of CPPopt-guided management starting in the first days after ictus is needed to confirm the clinical validity of this concept.
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Affiliation(s)
- Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Beate Kranawetter
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Sheri Tuzi
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
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Svedung Wettervik TM, Hånell A, Howells T, Ronne-Engström E, Lewén A, Enblad P. Individualized Autoregulation-Derived Cerebral Perfusion Targets in Aneurysmal Subarachnoid Hemorrhage: A New Therapeutic Avenue? J Intensive Care Med 2024:8850666241252415. [PMID: 38706245 DOI: 10.1177/08850666241252415] [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: 05/07/2024]
Abstract
Background: Cerebral perfusion pressure (CPP) is an important target in aneurysmal subarachnoid hemorrhage (aSAH), but it does not take into account autoregulatory disturbances. The pressure reactivity index (PRx) and the CPP with the optimal PRx (CPPopt) are new variables that may capture these pathomechanisms. In this study, we investigated the effect on the outcome of certain combinations of CPP or ΔCPPopt (actual CPP-CPPopt) with the concurrent autoregulatory status (PRx) after aSAH. Methods: This observational study included 432 aSAH patients, treated in the neurointensive care unit, at Uppsala University Hospital, Sweden. Functional outcome (GOS-E) was assessed 1-year postictus. Heatmaps of the percentage of good monitoring time (%GMT) of PRx/CPP and PRx/ΔCPPopt combinations in relation to GOS-E were created to visualize the association between these variables and outcome. Results: In the heatmap of the %GMT of PRx/CPP, the combination of lower CPP with higher PRx values was more strongly associated with lower GOS-E. The tolerance for lower CPP values increased with lower PRx values until a threshold of -0.50. However, for decreasing PRx below -0.50, there was a gradual reduction in the tolerance for lower CPP. In the heatmap of the %GMT of PRx/ΔCPPopt, the combination of negative ΔCPPopt with higher PRx values was strongly associated with lower GOS-E. In particular, negative ΔCPPopt together with PRx above +0.50 correlated with worse outcomes. In addition, there was a transition toward an unfavorable outcome when PRx went below -0.50, particularly if ΔCPPopt was negative. Conclusions: The PRx levels influenced the association between CPP/ΔCPPopt and outcome. Thus, this variable could be used to individualize a safe CPP-/ΔCPPopt-range.
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Affiliation(s)
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Svedung Wettervik T, Howells T, Hånell A, Lewén A, Enblad P. The Optimal pressure reactivity index range is disease-specific: A comparison between aneurysmal subarachnoid hemorrhage and traumatic brain injury. J Clin Monit Comput 2024:10.1007/s10877-024-01168-9. [PMID: 38702589 DOI: 10.1007/s10877-024-01168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Impaired cerebral pressure autoregulation is common and detrimental after acute brain injuries. Based on the prevalence of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH) patients compared to traumatic brain injury (TBI), we hypothesized that the type of autoregulatory disturbance and the optimal PRx range may differ between these two conditions. The aim of this study was to determine the optimal PRx ranges in relation to functional outcome following aSAH and TBI, respectively. METHODS In this observational study, 487 aSAH patients and 413 TBI patients, treated in the neurointensive care, Uppsala, Sweden, between 2008 and 2018, were included. The percentage of good monitoring time (%GMT) of PRx was calculated within 8 intervals covering the range from -1.0 to + 1.0, and analyzed in relation to favorable outcome (GOS-E 5 to 8). RESULTS In multiple logistic regressions, a higher %GMTs of PRx in the intervals -1.0 to -0.5 and + 0.75 to + 1.0 were independently associated with a lower rate of favorable outcome in the aSAH cohort. In a similar analysis in the TBI cohort, only positive PRx in the interval + 0.75 to + 1.0 was independently associated with a lower rate of favorable outcome. CONCLUSION Extreme PRx values in both directions were unfavorable in aSAH, possibly as high PRx could indicate proximal vasospasm with exhausted distal vasodilatory reserve, while very negative PRx could reflect myogenic hyperreactivity with suppressed cerebral blood flow. Only elevated PRx was unfavorable in TBI, possibly as pressure passive vessels may be a more predominant pathomechanism in this disease.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Leppert J, Ditz C, Souayah N, Behrens C, Tronnier VM, Küchler J. Limitations of prone positioning in patients with aneurysmal subarachnoid hemorrhage and concomitant respiratory failure. Clin Neurol Neurosurg 2023; 232:107878. [PMID: 37423091 DOI: 10.1016/j.clineuro.2023.107878] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/11/2023]
Abstract
OBJECTIVE Prone positioning (PP) is an established treatment modality for respiratory failure. After aneurysmal subarachnoid hemorrhage (aSAH), PP is rarely performed considering the risk of intracranial hypertension. The aim of this study was to analyze the effects of PP on intracranial pressure (ICP), cerebral perfusion pressure (CPP) and cerebral oxygenation following aSAH. PATIENTS AND METHODS Demographic and clinical data of aSAH patients admitted over a 6-year period and treated with PP due to respiratory insufficiency were retrospectively analyzed. ICP, CPP, brain tissue oxygenation (pBrO2), respiratory parameters and ventilator settings were analyzed before and during PP. RESULTS Thirty patients receiving invasive multimodal neuromonitoring were included. Overall, 97 PP sessions were performed. Mean arterial oxygenation and pBrO2 increased significantly during PP. We found a significant increase in median ICP compared to the baseline level in supine position. No significant changes in CPP were observed. Five PP sessions had to be terminated early due to medically refractory ICP-crisis. The affected patients were younger (p = 0.02) with significantly higher baseline ICP values (p = 0.009). Baseline ICP correlates significantly (p < 0.001) with ICP 1 h (R: 0.57) and 4 h (R: 0.55) after onset of PP. CONCLUSION PP in aSAH patients with respiratory insufficiency is an effective therapeutic option improving arterial and global cerebral oxygenation without compromising CPP. The significant increase in ICP was moderate in most sessions. However, as some patients experience intolerable ICP crises during PP, continuous ICP-Monitoring is considered mandatory. Patients with elevated baseline ICP and reduced intracranial compliance should not be considered for PP.
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Affiliation(s)
- Jan Leppert
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Claudia Ditz
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany.
| | - Noura Souayah
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Carianne Behrens
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Volker M Tronnier
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
| | - Jan Küchler
- Department of Neurosurgery, Universitätsklinikum Schleswig-Holstein, Campus Lübeck, Lübeck, Germany
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Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
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Kastenholz N, Megjhani M, Conzen-Dilger C, Albanna W, Veldeman M, Nametz D, Kwon SB, Schulze-Steinen H, Ridwan H, Clusmann H, Schubert GA, Park S, Weiss M. The oxygen reactivity index indicates disturbed local perfusion regulation after aneurysmal subarachnoid hemorrhage: an observational cohort study. Crit Care 2023; 27:235. [PMID: 37312192 PMCID: PMC10265851 DOI: 10.1186/s13054-023-04452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/19/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Cerebral autoregulation (CA) can be impaired in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The Pressure Reactivity Index (PRx, correlation of blood pressure and intracranial pressure) and Oxygen Reactivity Index (ORx, correlation of cerebral perfusion pressure and brain tissue oxygenation, PbtO2) are both believed to estimate CA. We hypothesized that CA could be poorer in hypoperfused territories during DCI and that ORx and PRx may not be equally effective in detecting such local variances. METHODS ORx and PRx were compared daily in 76 patients with aSAH with or without DCI until the time of DCI diagnosis. The ICP/PbtO2-probes of DCI patients were retrospectively stratified by being in or outside areas of hypoperfusion via CT perfusion image, resulting in three groups: DCI + /probe + (DCI patients, probe located inside the hypoperfused area), DCI + /probe- (probe outside the hypoperfused area), DCI- (no DCI). RESULTS PRx and ORx were not correlated (r = - 0.01, p = 0.56). Mean ORx but not PRx was highest when the probe was located in a hypoperfused area (ORx DCI + /probe + 0.28 ± 0.13 vs. DCI + /probe- 0.18 ± 0.15, p < 0.05; PRx DCI + /probe + 0.12 ± 0.17 vs. DCI + /probe- 0.06 ± 0.20, p = 0.35). PRx detected poorer autoregulation during the early phase with relatively higher ICP (days 1-3 after hemorrhage) but did not differentiate the three groups on the following days when ICP was lower on average. ORx was higher in the DCI + /probe + group than in the other two groups from day 3 onward. ORx and PRx did not differ between patients with DCI, whose probe was located elsewhere, and patients without DCI (ORx DCI + /probe- 0.18 ± 0.15 vs. DCI- 0.20 ± 0.14; p = 0.50; PRx DCI + /probe- 0.06 ± 0.20 vs. DCI- 0.08 ± 0.17, p = 0.35). CONCLUSIONS PRx and ORx are not interchangeable measures of autoregulation, as they likely measure different homeostatic mechanisms. PRx represents the classical cerebrovascular reactivity and might be better suited to detect disturbed autoregulation during phases with moderately elevated ICP. Autoregulation may be poorer in territories affected by DCI. These local perfusion disturbances leading up to DCI may be more readily detected by ORx than PRx. Further research should investigate their robustness to detect DCI and to serve as a basis for autoregulation-targeted treatment after aSAH.
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Affiliation(s)
- Nick Kastenholz
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Murad Megjhani
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Daniel Nametz
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Soon Bin Kwon
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Henna Schulze-Steinen
- Department of Intensive Care Medicine and Perioperative Care, RWTH Aachen University, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Soojin Park
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
- Department of Biomedical Informatics, Columbia University, New York City, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
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Chang JJ, Kepplinger D, Metter EJ, Felbaum DR, Mai JC, Armonda RA, Aulisi EF. Pressure reactivity index for early neuroprognostication in poor-grade subarachnoid hemorrhage. J Neurol Sci 2023; 450:120691. [PMID: 37267816 DOI: 10.1016/j.jns.2023.120691] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Pressure reactivity index (PRx) utilizes moving correlation coefficients from intracranial pressure (ICP) and mean arterial pressures to evaluate cerebral autoregulation. We evaluated patients with poor-grade subarachnoid hemorrhage (SAH), identified their PRx trajectories over time, and identified threshold time points where PRx could be used for neuroprognostication. METHODS Patients with poor-grade SAH were identified and received continuous bolt ICP measurements. Dichotomized outcomes were based on ninety-day modified Rankin scores and disposition. Smoothed PRx trajectories for each patient were created to generate "candidate features" that looked at daily average PRx, cumulative first-order changes in PRx, and cumulative second-order changes in PRx. "Candidate features" were then used to perform penalized logistic regression analysis using poor outcome as the dependent variable. Penalized logistic regression models that maximized specificity for poor outcome were generated over several time periods and evaluated how sensitivities changed over time. RESULTS 16 patients with poor-grade SAH were evaluated. Average PRx trajectories for the good (PRx < 0.25) and poor outcome groups (PRx > 0.5) started diverging at post-ictus day 8. When targeting specificities ≥88% for poor outcome, sensitivities for poor outcome consistently increased to >70% starting at post-ictus days 12-14 with a maximum sensitivity of 75% occurring at day 18. CONCLUSIONS Our results suggest that by using PRx trends, early neuroprognostication in patients with SAH and poor clinical exams may start becoming apparent at post-ictus day 8 and reach adequate sensitivities by post-ictus days 12-14. Further study is required to validate this in larger poor-grade SAH populations.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA; Department of Neurology, Georgetown University Medical Center, Washington, DC, USA.
| | - David Kepplinger
- Department of Statistics, George Mason University, Fairfax, VA, USA
| | - E Jeffrey Metter
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Edward F Aulisi
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
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9
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Svedung Wettervik T, Hånell A, Howells T, Ronne Engström E, Lewén A, Enblad P. ICP, CPP, and PRx in traumatic brain injury and aneurysmal subarachnoid hemorrhage: association of insult intensity and duration with clinical outcome. J Neurosurg 2023; 138:446-453. [PMID: 35901752 DOI: 10.3171/2022.5.jns22560] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The primary aim of this study was to determine the combined effect of insult intensity and duration of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and pressure reactivity index (PRx) on outcome measured with the Glasgow Outcome Scale-Extended (GOS-E) in patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH). METHODS This observational study included all TBI and aSAH patients treated in the neurointensive care unit in Uppsala, Sweden, 2008-2018, with at least 24 hours of ICP monitoring during the first 10 days following injury and available long-term clinical outcome data. ICP, CPP, and PRx insults were visualized as 2D plots to highlight the effects of both insult intensity and duration on patient outcome. RESULTS Of 950 included patients, 436 were TBI and 514 aSAH patients. The TBI patients were younger, more often male, and exhibited worse neurological status at admission, but recovered more favorably than the aSAH patients. There was a transition from good to poor outcome with ICP above 15-20 mm Hg in both TBI and aSAH. The two diagnoses had opposite CPP patterns. In TBI patients, CPP episodes at or below 80 mm Hg were generally favorable, whereas CPP episodes above 80 mm Hg were favorable in the aSAH patients. In the TBI patients there was a transition from good to poor outcome when PRx exceeded zero, but no evident transition was found in the aSAH cohort. CONCLUSIONS The insult intensity and duration plots formulated in this study illustrate the similarities and differences between TBI and aSAH patients. In particular, aSAH patients may benefit from much higher CPP targets than TBI patients.
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Affiliation(s)
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Gelormini C, Caricato A, Pastorino R, Guerino Biasucci D, Ioannoni E, Montano N, Stival E, Signorelli F, Melchionda I, Albanese A, Marchese E, Silva S, Antonelli M. Brain tissue oxygenation monitoring in subarachnoid hemorrhage for the detection of delayed ischemia: a systematic review and meta-analysis. Minerva Anestesiol 2023; 89:96-103. [PMID: 36745118 DOI: 10.23736/s0375-9393.22.16468-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
INTRODUCTION Subarachnoid hemorrhage (SAH) is a severe subtype of stroke which can be caused by the rupture of an intracranial aneurysm. Following SAH, about 30% of patients develop a late neurologic deterioration due to a delayed cerebral ischemia (DCI). This is a metanalysis and systematic review on the association between values of brain tissue oxygenation (PbtO2) and DCI in patients with SAH. EVIDENCE ACQUISITION The protocol was written according to the PRISMA-P (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines and approved by the International Prospective Register of Systematic Reviews (PROSPERO registration number CRD42021229338). Relevant literature published up to August 1, 2022 was systematically searched throughout the databases MEDLINE, WEB OF SCIENCE, SCOPUS. A systematic review and metanalysis was carried out. The studies considered eligible were those published in English; that enrolled adult patients (≥18years) admitted to neurointensive care units with aneurysmal SAH (aSAH); that reported presence of multimodality monitoring including PbtO2 and detection of DCI during the period of monitoring. EVIDENCE SYNTHESIS We founded 286 studies, of which six considered eligible. The cumulative mean of PbtO2 was 19.5 mmHg in the ischemic group and 24.1mmHg in the non ischemic group. The overall mean difference of the values of PbtO2 between the patients with or without DCI resulted significantly different (-4.32 mmHg [IC 95%: -5.70, -2.94], without heterogeneity, I2 = 0%, and a test for overall effect with P<0.00001). CONCLUSIONS PbtO2 values were significantly lower in patients with DCI. Waiting for definitive results, monitoring of PbtO2 should be considered as a complementary parameter for multimodal monitoring of the risk of DCI in patients with SAH.
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Affiliation(s)
- Camilla Gelormini
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy -
| | - Anselmo Caricato
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Roberta Pastorino
- Department of Woman, Child, and Public Health, Gemelli University Hospital IRCCS, Rome, Italy
| | - Daniele Guerino Biasucci
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Eleonora Ioannoni
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Nicola Montano
- Section of Neurosurgery, Department of Neuroscience, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Eleonora Stival
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Francesco Signorelli
- Section of Neurosurgery, Department of Neuroscience, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Isabella Melchionda
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Alessio Albanese
- Section of Neurosurgery, Department of Neuroscience, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Enrico Marchese
- Section of Neurosurgery, Department of Neuroscience, IRCCS A. Gemelli University Polyclinic Foundation, Sacred Heart Catholic University, Rome, Italy
| | - Serena Silva
- Unit of Neurointensive Care, Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Massimo Antonelli
- Department of Anesthesiology, Intensive Care and Emergency Medicine, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
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11
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Nogueira RC, Aries M, Minhas JS, H Petersen N, Xiong L, Kainerstorfer JM, Castro P. Review of studies on dynamic cerebral autoregulation in the acute phase of stroke and the relationship with clinical outcome. J Cereb Blood Flow Metab 2022; 42:430-453. [PMID: 34515547 PMCID: PMC8985432 DOI: 10.1177/0271678x211045222] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute stroke is associated with high morbidity and mortality. In the last decades, new therapies have been investigated with the aim of improving clinical outcomes in the acute phase post stroke onset. However, despite such advances, a large number of patients do not demonstrate improvement, furthermore, some unfortunately deteriorate. Thus, there is a need for additional treatments targeted to the individual patient. A potential therapeutic target is interventions to optimize cerebral perfusion guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). This narrative led to the development of the INFOMATAS (Identifying New targets FOr Management And Therapy in Acute Stroke) project, designed to foster interventions directed towards understanding and improving hemodynamic aspects of the cerebral circulation in acute cerebrovascular disease states. This comprehensive review aims to summarize relevant studies on assessing dCA in patients suffering acute ischemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage. The review will provide to the reader the most consistent findings, the inconsistent findings which still need to be explored further and discuss the main limitations of these studies. This will allow for the creation of a research agenda for the use of bedside dCA information for prognostication and targeted perfusion interventions.
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Affiliation(s)
- Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Department of Neurology, Hospital Nove de Julho, São Paulo, Brazil
| | - Marcel Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center+, School for Mental Health and Neuroscience (MHeNS), Maastricht, The Netherlands
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, USA
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jana M Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, USA.,Neuroscience Institute, Carnegie Mellon University, Pittsburgh, USA
| | - Pedro Castro
- Department of Neurology, Faculty of Medicine of University of Porto, Centro Hospitalar Universitário de São João, Porto, Portugal
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12
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Svedung Wettervik T, Fahlström M, Enblad P, Lewén A. Cerebral Pressure Autoregulation in Brain Injury and Disorders-A Review on Monitoring, Management, and Future Directions. World Neurosurg 2021; 158:118-131. [PMID: 34775084 DOI: 10.1016/j.wneu.2021.11.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 12/14/2022]
Abstract
The role of cerebral pressure autoregulation (CPA) in brain injury and disorders has gained increased interest. The CPA is often disturbed as a consequence of acute brain injury, which contributes to further brain damage and worse outcome. Specifically, in severe traumatic brain injury, CPA disturbances predict worse clinical outcome and targeting an autoregulatory-oriented optimal cerebral perfusion pressure threshold may improve brain energy metabolism and clinical outcome. In aneurysmal subarachnoid hemorrhage, cerebral vasospasm in combination with distal autoregulatory disturbances precipitate delayed cerebral ischemia. The role of optimal cerebral perfusion pressure targets is less clear in aneurysmal subarachnoid hemorrhage, but high cerebral perfusion pressure targets are generally favorable in the vasospasm phase. In acute ischemia, autoregulatory disturbances may occur and autoregulatory-oriented blood pressure (optimal mean arterial pressure) management reduces the risk of hemorrhagic transformation, brain edema, and unfavorable outcome. In chronic occlusive disease such as moyamoya, the gradual reduction of the cerebral circulation leads to compensatory distal vasodilation and the residual CPA capacity predicts the risk for cerebral ischemia. In spontaneous intracerebral hemorrhage, the role of autoregulatory disturbances is less clear, but CPA disturbances correlate with worse clinical outcome. Also, in community-acquired bacterial meningitis, CPA dysfunction is frequent and correlates with worse clinical outcome, but autoregulatory management is yet to be evaluated. In this review, we discuss the role of CPA in different types of brain injury and disease, the strengths and limitations of the monitoring methods, the potentials of autoregulatory management, and future directions in the field.
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Affiliation(s)
| | - Markus Fahlström
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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13
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Gouvea Bogossian E, Diaferia D, Ndieugnou Djangang N, Menozzi M, Vincent JL, Talamonti M, Dewitte O, Peluso L, Barrit S, Al Barajraji M, Andre J, Schuind S, Creteur J, Taccone FS. Brain tissue oxygenation guided therapy and outcome in non-traumatic subarachnoid hemorrhage. Sci Rep 2021; 11:16235. [PMID: 34376735 PMCID: PMC8355344 DOI: 10.1038/s41598-021-95602-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023] Open
Abstract
Brain hypoxia can occur after non-traumatic subarachnoid hemorrhage (SAH), even when levels of intracranial pressure (ICP) remain normal. Brain tissue oxygenation (PbtO2) can be measured as a part of a neurological multimodal neuromonitoring. Low PbtO2 has been associated with poor neurologic recovery. There is scarce data on the impact of PbtO2 guided-therapy on patients’ outcome. This single-center cohort study (June 2014–March 2020) included all patients admitted to the ICU after SAH who required multimodal monitoring. Patients with imminent brain death were excluded. Our primary goal was to assess the impact of PbtO2-guided therapy on neurological outcome. Secondary outcome included the association of brain hypoxia with outcome. Of the 163 patients that underwent ICP monitoring, 62 were monitored with PbtO2 and 54 (87%) had at least one episode of brain hypoxia. In patients that required treatment based on neuromonitoring strategies, PbtO2-guided therapy (OR 0.33 [CI 95% 0.12–0.89]) compared to ICP-guided therapy had a protective effect on neurological outcome at 6 months. In this cohort of SAH patients, PbtO2-guided therapy might be associated with improved long-term neurological outcome, only when compared to ICP-guided therapy.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Daniela Diaferia
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Narcisse Ndieugnou Djangang
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Menozzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marta Talamonti
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Olivier Dewitte
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sami Barrit
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mejdeddine Al Barajraji
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Joachim Andre
- Department of Radiology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
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14
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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15
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Svedung Wettervik T, Howells T, Lewén A, Ronne-Engström E, Enblad P. Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome. Neurocrit Care 2021; 34:390-402. [PMID: 33420669 PMCID: PMC8128752 DOI: 10.1007/s12028-020-01162-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND High intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome. METHODS In this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008-2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP-CPPopt) < - 10 mm Hg (%). RESULTS Of the 242 patients, 63 (26%) had favorable (GOS-E 5-8) and 179 (74%) had unfavorable (GOS-E 1-4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5-10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups. CONCLUSIONS Avoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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16
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Ipertensione intracranica. Neurologia 2021. [DOI: 10.1016/s1634-7072(21)44503-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
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17
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Liu X, Gu Y, Huang C, Zhao M, Cheng Y, Jawdeh EGA, Bada HS, Chen L, Yu G. Simultaneous measurements of tissue blood flow and oxygenation using a wearable fiber-free optical sensor. JOURNAL OF BIOMEDICAL OPTICS 2021; 26:JBO-200314RR. [PMID: 33515216 PMCID: PMC7846117 DOI: 10.1117/1.jbo.26.1.012705] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/25/2020] [Accepted: 01/12/2021] [Indexed: 05/08/2023]
Abstract
SIGNIFICANCE There is an essential need to develop wearable multimodality technologies that can continuously measure both blood flow and oxygenation in deep tissues to investigate and manage various vascular/cellular diseases. AIM To develop a wearable dual-wavelength diffuse speckle contrast flow oximetry (DSCFO) for simultaneous measurements of blood flow and oxygenation variations in deep tissues. APPROACH A wearable fiber-free DSCFO probe was fabricated using 3D printing to confine two small near-infrared laser diodes and a tiny CMOS camera in positions for DSCFO measurements. The spatial diffuse speckle contrast and light intensity measurements at the two different wavelengths enable quantification of tissue blood flow and oxygenation, respectively. The DSCFO was first calibrated using tissue phantoms and then tested in adult forearms during artery cuff occlusion. RESULTS Phantom tests determined the largest effective source-detector distance (15 mm) and optimal camera exposure time (10 ms) and verified the accuracy of DSCFO in measuring absorption coefficient variations. The DSCFO detected substantial changes in forearm blood flow and oxygenation resulting from the artery occlusion, which meet physiological expectations and are consistent with previous study results. CONCLUSIONS The wearable DSCFO may be used for continuous and simultaneous monitoring of blood flow and oxygenation variations in freely behaving subjects.
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Affiliation(s)
- Xuhui Liu
- University of Kentucky, Department of Biomedical Engineering, Lexington, Kentucky, United States
| | - Yutong Gu
- University of Kentucky, Department of Biomedical Engineering, Lexington, Kentucky, United States
| | - Chong Huang
- University of Kentucky, Department of Biomedical Engineering, Lexington, Kentucky, United States
| | - Mingjun Zhao
- University of Kentucky, Department of Biomedical Engineering, Lexington, Kentucky, United States
| | - Yanda Cheng
- University of Kentucky, Department of Biomedical Engineering, Lexington, Kentucky, United States
| | - Elie G. Abu Jawdeh
- University of Kentucky, Department of Pediatrics, College of Medicine, Lexington, Kentucky, United States
| | - Henrietta S. Bada
- University of Kentucky, Department of Pediatrics, College of Medicine, Lexington, Kentucky, United States
| | - Lei Chen
- University of Kentucky, Department of Physiology, Spinal Cord and Brain Injury Research Center, Lexington, Kentucky, United States
| | - Guoqiang Yu
- University of Kentucky, Department of Biomedical Engineering, Lexington, Kentucky, United States
- Address all correspondence to Guoqiang Yu,
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18
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Silverman A, Kodali S, Strander S, Gilmore EJ, Kimmel A, Wang A, Cord B, Falcone G, Hebert R, Matouk C, Sheth KN, Petersen NH. Deviation From Personalized Blood Pressure Targets Is Associated With Worse Outcome After Subarachnoid Hemorrhage. Stroke 2019; 50:2729-2737. [PMID: 31495332 PMCID: PMC6756936 DOI: 10.1161/strokeaha.119.026282] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Optimal blood pressure (BP) management during the early stages of aneurysmal subarachnoid hemorrhage remains uncertain. Observational studies have found worse outcomes in patients with increased hemodynamic variability, suggesting BP optimization as a potential neuroprotective strategy. In this study, we calculated personalized BP targets at which cerebral autoregulation was best preserved. We analyzed how deviation from these limits correlates with functional outcome. Methods- We prospectively enrolled 31 patients with aneurysmal subarachnoid hemorrhage. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy (NIRS)-derived tissue oxygenation-a surrogate for cerebral blood flow-as well as intracranial pressure (ICP) in response to changes in mean arterial pressure using time-correlation analysis. The resulting autoregulatory indices were used to identify the upper and lower limit of autoregulation. Percent time that mean arterial pressure exceeded limits of autoregulation was calculated for each patient. Functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using ordinal multivariate logistic regression. Results- Personalized limits of autoregulation were computed in all patients (age 57.5±13.4, 23F, mean World Federation of Neurological Surgeons 2±1, monitoring time 67.8±50.8 hours). Optimal BP and limits of autoregulation were calculated on average for 89.5±6.7% of the total monitoring period. ICP- and NIRS-derived optimal pressures strongly correlated with one another (P<0.0001). Percent time that mean arterial pressure deviated from limits of autoregulation significantly associated with worse functional outcome at discharge (NIRS, P=0.001; ICP, P=0.004) and 90 days (NIRS, P=0.002; ICP, P=0.003), adjusting separately for age, World Federation of Neurological Surgeons, vasospasm, and delayed cerebral ischemia. Conclusions- Both invasive (ICP) and noninvasive (NIRS) determination of personalized BP targets after aneurysmal subarachnoid hemorrhage is feasible, and these 2 approaches revealed significant collinearity. Furthermore, exceeding individualized limits of autoregulation was associated with poor functional outcomes.
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Affiliation(s)
| | - Sreeja Kodali
- Department of Neurology, Yale Medical School, New Haven, CT
| | | | | | | | - Anson Wang
- Department of Neurology, Yale Medical School, New Haven, CT
| | - Branden Cord
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Guido Falcone
- Department of Neurology, Yale Medical School, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Charles Matouk
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Kevin N. Sheth
- Department of Neurology, Yale Medical School, New Haven, CT
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19
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Andresen M, Donnelly J, Aries M, Juhler M, Menon D, Hutchinson P, Smielewski P. Further Controversies About Brain Tissue Oxygenation Pressure-Reactivity After Traumatic Brain Injury. Neurocrit Care 2019; 28:162-168. [PMID: 28819737 DOI: 10.1007/s12028-017-0438-z] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND Continuous monitoring of cerebral autoregulation is considered clinically useful due to its ability to warn against brain ischemic insults, which may translate to a relationship with adverse outcome. It is typically performed using the pressure reactivity index (PRx) based on mean arterial pressure and intracranial pressure. A new ORx index based on brain tissue oxygenation and cerebral perfusion pressure (CPP) has been proposed that similarly allows for evaluation of cerebrovascular reactivity. Conflicting results exist concerning its clinical utility. METHODS Retrospective analysis was performed in 85 patients with traumatic brain injury (TBI). ORx was calculated using three time windows of 5, 20, and 60 min. Correlation coefficients and individual "optimal CPP" (CPPopt) were calculated using both PRx and ORx, and relation to patient outcome investigated. RESULTS Correlation coefficients for all comparisons between PRx and ORx indicated poor association between these indices (range from -0.04 to 0.07). PRx was significantly lower in patients with good outcome (p = 0.01), while none of the ORx indices proved to be significantly different in the two outcome groups. Higher mortality related to average CPP < CPPopt was found regardless of which index was used to calculate CPPopt. CONCLUSION In the TBI setting, ORx does not appear to correlate with vascular pressure reactivity as assessed with PRx. Its potential use for individualizing CPP thresholds remains unclear.
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Affiliation(s)
- Morten Andresen
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK.
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark.
| | - Joseph Donnelly
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
| | - Marcel Aries
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
- Department of Neurology, University of Groningen, Groningen, The Netherlands
| | - Marianne Juhler
- Clinic of Neurosurgery, Copenhagen University Hospital, Rigshospitalet, Copenhagen, Denmark
| | - David Menon
- Division of Anesthesiology, Cambridge University Hospital, Cambridge, UK
| | - Pja Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge University Hospital, Cambridge, UK
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20
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Al-Mufti F, Lander M, Smith B, Morris NA, Nuoman R, Gupta R, Lissauer ME, Gupta G, Lee K. Multimodality Monitoring in Neurocritical Care: Decision-Making Utilizing Direct And Indirect Surrogate Markers. J Intensive Care Med 2018; 34:449-463. [PMID: 30205730 DOI: 10.1177/0885066618788022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Substantial progress has been made to create innovative technology that can monitor the different physiological characteristics that precede the onset of secondary brain injury, with the ultimate goal of intervening prior to the onset of irreversible neurological damage. One of the goals of neurocritical care is to recognize and preemptively manage secondary neurological injury by analyzing physiologic markers of ischemia and brain injury prior to the development of irreversible damage. This is helpful in a multitude of neurological conditions, whereby secondary neurological injury could present including but not limited to traumatic intracranial hemorrhage and, specifically, subarachnoid hemorrhage, which has the potential of progressing to delayed cerebral ischemia and monitoring postneurosurgical interventions. In this study, we examine the utilization of direct and indirect surrogate physiologic markers of ongoing neurologic injury, including intracranial pressure, cerebral blood flow, and brain metabolism.
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Affiliation(s)
- Fawaz Al-Mufti
- 1 Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,2 Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Megan Lander
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Brendan Smith
- 4 Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Nicholas A Morris
- 5 Department of Neurology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rolla Nuoman
- 6 Department of Neurology, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Rajan Gupta
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Matthew E Lissauer
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Gaurav Gupta
- 7 Division of Neurosurgery, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kiwon Lee
- 1 Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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Gaasch M, Schiefecker AJ, Kofler M, Beer R, Rass V, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Cerebral Autoregulation in the Prediction of Delayed Cerebral Ischemia and Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients*. Crit Care Med 2018; 46:774-780. [DOI: 10.1097/ccm.0000000000003016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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22
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Copplestone S, Welbourne J. A narrative review of the clinical application of pressure reactiviy indices in the neurocritical care unit. Br J Neurosurg 2018; 32:4-12. [PMID: 29298527 DOI: 10.1080/02688697.2017.1416063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pressure reactivity indices are used in clinical research as a surrogate marker of the ability of the cerebrovasculature to maintain cerebral autoregulation. The use of pressure reactivity indices in patients with neurological injury represents a potential to move away from population-based physiological targets used in guidelines to individualized physiological targets. The aim of this review is to describe the underlying principles and development of pressure reactivity indices, alongside a critique of how they have been used in clinical research, including their limitations. The primary source literature was identified from a database search of PUBMed and OVID online using the search terms "pressure reactivity index" and "pressure reactivity indices". The evidence base regarding pressure reactivity indices currently remains Level III. Pressure reactivity indices rely on the correlation (-1 to +1) between the arterial blood pressure and intracranial pressure, with negative values indicating intact cerebral autoregulation and positive values indicating dysfunctional cerebral autoregulation. Meaningful data is taken from summary measures and trends. The traumatic brain injury population feature most prominently in the literature. There is limited description of the potential confounding factors that may affect pressure reactivity indices, including physiological parameters and therapeutic interventions. Plotting a pressure reactivity index against a cerebral perfusion pressure can indicate an optimal cerebral perfusion pressure to individualise patient care. There is potential to over interpret optimal cerebral perfusion pressure targets when the values of pressure reactivity indices are close to zero. There is an association between pressure reactivity indices and neurological outcomes, however the use of pressure reactivity indices as a prognostication tool is to be challenged. Average values of cerebral perfusion pressure that are not close to averaged values of optimal cerebral perfusion pressure are also associated with poor outcome. Further research is required to ascertain whether targeting an optimal cerebral perfusion pressure may alter outcome.
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Affiliation(s)
- Stephen Copplestone
- a Advanced trainee in Intensive Care Medicine and Anaesthesia , Plymouth Hospitals NHS Trust , Plymouth , UK
| | - Jessie Welbourne
- b Consultant in Intensive Care Medicine and Neuroanaesthesia, Department of Intensive Care Medicine , Plymouth Hospitals NHS Trust , Plymouth , UK
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Johnson U, Engquist H, Howells T, Nilsson P, Ronne-Engström E, Lewén A, Rostami E, Enblad P. Bedside Xenon-CT Shows Lower CBF in SAH Patients with Impaired CBF Pressure Autoregulation as Defined by Pressure Reactivity Index (PRx). Neurocrit Care 2017; 25:47-55. [PMID: 26842717 DOI: 10.1007/s12028-016-0240-3] [Citation(s) in RCA: 19] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND Subarachnoid hemorrhage (SAH) is a disease with a high rate of unfavorable outcome, often related to delayed cerebral ischemia (DCI), i.e., ischemic injury that develops days-weeks after onset, with a multifactorial etiology. Disturbances in cerebral pressure autoregulation, the ability to maintain a steady cerebral blood flow (CBF), despite fluctuations in systemic blood pressure, have been suggested to play a role in the development of DCI. Pressure reactivity index (PRx) is a well-established measure of cerebral pressure autoregulation that has been used to study traumatic brain injury, but not extensively in SAH. OBJECTIVE To study the relation between PRx and CBF in SAH patients, and to examine if PRx can be used to predict DCI. METHODS Retrospective analysis of prospectively collected data. PRx was calculated as the correlation coefficient between mean arterial blood pressure (MABP) and intracranial pressure (ICP) in a 5 min moving window. CBF was measured using bedside Xenon-CT (Xe-CT). DCI was diagnosed clinically. RESULTS 47 poor-grade mechanically ventilated patients were studied. Patients with disturbed pressure autoregulation (high PRx values) had lower CBF, as measured by bedside Xe-CT; both in the early (day 0-3) and late (day 4-14) acute phase of the disease. PRx did not differ significantly between patients who developed DCI or not. CONCLUSION In mechanically ventilated and sedated SAH patients, high PRx (more disturbed CBF pressure autoregulation) is associated with low CBF, both day 0-3 and day 4-14 after onset. The role of PRx as a monitoring tool in SAH patients needs further studying.
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Affiliation(s)
- Ulf Johnson
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden. .,Department of Surgical Sciences/Radiology, Uppsala University, Uppsala, Sweden.
| | - Henrik Engquist
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden.,Department of Surgical Sciences/Anesthesia and Intensive Care, Uppsala University, Uppsala, Sweden
| | - Tim Howells
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Elham Rostami
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience/Neurosurgery, Uppsala University, Uppsala, Sweden
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Abstract
Abstract
This comprehensive review summarizes the evidence regarding use of cerebral autoregulation-directed therapy at the bedside and provides an evaluation of its impact on optimizing cerebral perfusion and associated functional outcomes. Multiple studies in adults and several in children have shown the feasibility of individualizing mean arterial blood pressure and cerebral perfusion pressure goals by using cerebral autoregulation monitoring to calculate optimal levels. Nine of these studies examined the association between cerebral perfusion pressure or mean arterial blood pressure being above or below their optimal levels and functional outcomes. Six of these nine studies (66%) showed that patients for whom median cerebral perfusion pressure or mean arterial blood pressure differed significantly from the optimum, defined by cerebral autoregulation monitoring, were more likely to have an unfavorable outcome. The evidence indicates that monitoring of continuous cerebral autoregulation at the bedside is feasible and has the potential to be used to direct blood pressure management in acutely ill patients.
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Johnson U, Engquist H, Lewén A, Howells T, Nilsson P, Ronne-Engström E, Rostami E, Enblad P. Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP. Acta Neurochir (Wien) 2017; 159:1065-1071. [PMID: 28361248 PMCID: PMC5425502 DOI: 10.1007/s00701-017-3139-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/27/2017] [Indexed: 01/23/2023]
Abstract
Background Cerebral pressure autoregulation can be quantified with the pressure reactivity index (PRx), based on the correlation between blood pressure and intracranial pressure. Using PRx optimal cerebral perfusion pressure (CPPopt) can be calculated, i.e., the level of CPP where autoregulation functions best. The relation between cerebral blood flow (CBF) and CPPopt has not been examined. The objective was to assess to which extent CPPopt can be calculated in SAH patients and to investigate CPPopt in relation to CBF. Methods Retrospective study of prospectively collected data. CBF was measured bedside with Xenon-enhanced CT (Xe-CT). The difference between actual CPP and CPPopt was calculated (CPP∆). Correlations between CPP∆ and CBF parameters were calculated with Spearman’s rank order correlation coefficient (rho). Separate calculations were done using all patients (day 0–14 after onset) as well as in two subgroups (day 0–3 and day 4–14). Results Eighty-two patients with 145 Xe-CT scans were studied. Automated calculation of CPPopt was possible in adjunct to 60% of the Xe-CT scans. Actual CPP < CPPopt was associated with higher numbers of low-flow regions (CBF <10 ml/100 g/min) in both the early phase (day 0–3, n = 39, Spearman’s rho = −0.38, p = 0.02) and late acute phase of the disease (day 4–14, n = 35, Spearman’s rho = −0.39, p = 0.02). CPP level per se was not associated with CBF. Conclusions Calculation of CPPopt is possible in a majority of patients with severe SAH. Actual CPP below CPPopt is associated with low CBF.
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Affiliation(s)
- Ulf Johnson
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden.
- Department of Surgical sciences/Radiology, Uppsala University, Uppsala, Sweden.
| | - Henrik Engquist
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
- Department of Surgical sciences/Anaesthesia and Intensive care, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | - Tim Howells
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | | | - Elham Rostami
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
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Schmidt B, Reinhard M, Lezaic V, McLeod DD, Weinhold M, Mattes H, Klingelhöfer J. Autoregulation monitoring and outcome prediction in neurocritical care patients: Does one index fit all? J Clin Monit Comput 2016; 30:367-75. [PMID: 26085437 PMCID: PMC4854943 DOI: 10.1007/s10877-015-9726-3] [Citation(s) in RCA: 23] [Impact Index Per Article: 2.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2015] [Accepted: 06/13/2015] [Indexed: 11/17/2022]
Abstract
Indexes PRx and Mx have been formerly introduced to assess cerebral autoregulation and have been shown to be associated with 3-month clinical outcome. In a mixed cohort of neurocritical care patients, we retrospectively investigated the impact of selected clinical characteristics on this association. Forty-one patients (18-77 years) with severe traumatic (TBI, N = 20) and non-traumatic (N = 21) brain injuries were studied. Cerebral blood flow velocity, arterial blood pressure and intracranial pressure were repeatedly recorded during 1-h periods. Calculated PRx and Mx were correlated with 3-month clinical outcome score of modified Rankin Scale (mRS) in different subgroups with specific clinical characteristics. Both PRx and Mx correlated significantly with outcome (PRx: r = 0.38, p < 0.05; AUC = 0.64, n.s./Mx: r = 0.48, p < 0.005; AUC = 0.80, p < 0.005) in the overall group, and in patients with hemicraniectomy (N = 17; PRx: r = 0.73, p < 0.001; AUC = 0.89, p < 0.01/Mx: r = 0.69, p < 0.005; AUC = 0.87, p < 0.05). Mx, not PRx, correlated significantly with mRS in patients with heart failure (N = 17; r = 0.69, p < 0.005; AUC = 0.92, p < 0.005), and in non-traumatic patients (r = 0.49, p < 0.05; AUC = 0.79, p < 0.05). PRx, not Mx, correlated significantly with mRS in TBI patients (r = 0.63, p < 0.01; AUC = 0.89, p < 0.01). Both indexes did not correlate with mRS in diabetes patients (N = 15), PRx failed in hypocapnic patients (N = 26). Both PRx and Mx were significantly associated with 3-month clinical outcome, even in patients with hemicraniectomy. PRx was more appropriate for TBI patients, while Mx was better suited for non-traumatic patients and patients with heart failure. Prognostic values of indexes were affected by diabetes (both Mx and PRx) and hypocapnia (PRx only).
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Affiliation(s)
- Bernhard Schmidt
- Department of Neurology, Chemnitz Medical Centre, Dresdner Str. 178, 09131, Chemnitz, Germany.
| | - Matthias Reinhard
- Department of Neurology, University of Freiburg, Breisacher Str. 64, 79106, Freiburg, Germany
| | - Vesna Lezaic
- Department of Neurology, Chemnitz Medical Centre, Dresdner Str. 178, 09131, Chemnitz, Germany
| | - Damian D McLeod
- School of Biomedical Sciences and Pharmacy, The University of Newcastle, Callaghan, NSW, 2308, Australia
| | - Marco Weinhold
- Department of Neurology, Chemnitz Medical Centre, Dresdner Str. 178, 09131, Chemnitz, Germany
| | - Heinz Mattes
- Department of Electrical, Electronic and Communication Engineering, Friedrich-Alexander Universität Erlangen-Nürnberg, 91052, Erlangen, Germany
| | - Jürgen Klingelhöfer
- Department of Neurology, Chemnitz Medical Centre, Dresdner Str. 178, 09131, Chemnitz, Germany
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Ko SB, Choi HA, Helbok R, Kurtz P, Schmidt JM, Badjatia N, Claassen J, Connolly ES, Mayer SA, Lee K. Acute effects of intraventricular nicardipine on cerebral hemodynamics: A preliminary finding. Clin Neurol Neurosurg 2016; 144:48-52. [PMID: 26971295 DOI: 10.1016/j.clineuro.2016.02.037] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2016] [Revised: 02/26/2016] [Accepted: 02/27/2016] [Indexed: 11/28/2022]
Abstract
OBJECTIVE Intraventricular nicardipine (IVTN) is a treatment option for severe vasospasm in patients with subarachnoid hemorrhage (SAH). However, its acute effects on cerebral hemodynamics have not been studied in detail. METHODS Between June 2008 and December 2010, IVTN was administered (mainly 4mg every 8h) to 11 SAH patients (54 doses) with multimodality monitoring for refractory vasospasm. Retrospective analyses on physiological parameters were made from baseline and up to 6h after IVTN injection. Statistical analysis was performed with a mixed-effects model. RESULTS Mean intracranial pressure (ICP) increased slightly, reaching its peak at 20min after IVTN injection (2.5±0.9mmHg (mean±standard error), P<0.01), and decreased gradually thereafter over the next hour. Mean cerebral perfusion pressure transiently decreased 20-30min after injection (3.7±1.8mmHg, P<0.05). Mean arterial pressure, partial pressure of brain oxygen tension (PbtO2), cerebral blood flow (CBF), autoregulation indices did not change significantly. Lactate/pyruvate ratio and glucose remained stable. One patient underwent transcranial Doppler ultrasonography monitoring while on IVTN, which showed a transient increase in mean flow velocity with concomitant decrease in Pulsatility index, suggesting vasodilation in the distal resistance vessels. CONCLUSIONS The vasodilatory effect of IVTN transiently increased ICP, but did not significantly affect PbtO2, CBF or oxidative glucose metabolism in the immediate phase after injection.
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Affiliation(s)
- Sang-Bae Ko
- Department of Neurology, Seoul National University Hospital, Seoul, Republic of Korea
| | - H Alex Choi
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA
| | - Raimund Helbok
- Clinical Department of Neurology, Medical University Innsbruck, Innsbruck, Austria
| | - Pedro Kurtz
- Neuro Intensive Care Unit, Brain Institute Paulo Niemeyer, Rio de Janeiro, RJ, Brazil
| | - J Michael Schmidt
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Neeraj Badjatia
- Section of Neurocritical Care, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, MD, USA
| | - Jan Claassen
- Department of Neurology, Columbia University College of Physicians and Surgeons, New York, NY, USA; Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - E Sander Connolly
- Department of Neurosurgery, Columbia University College of Physicians and Surgeons, New York, NY, USA
| | - Stephan A Mayer
- Departments of Neurology and Neurosurgery, Institute for Critical Care Medicine, Icahn School of Medicine at Mount Sinai, New York, NY, USA
| | - Kiwon Lee
- Department of Neurology and Neurosurgery, The Mischer Neuroscience Institute, Memorial Hermann of Texas Medical Center, Houston, TX, USA.
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28
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Schmidt B, Lezaic V, Weinhold M, Plontke R, Schwarze J, Klingelhöfer J. Is Impaired Autoregulation Associated with Mortality in Patients with Severe Cerebral Diseases? ACTA NEUROCHIRURGICA. SUPPLEMENT 2016; 122:181-185. [PMID: 27165903 DOI: 10.1007/978-3-319-22533-3_37] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) is a mechanism that compensates for variations in cerebral perfusion pressure (CPP) by changes in cerebral blood flow resistance to keep the cerebral blood flow constant. In this study, the relationship between lethal outcome during hospitalisation and the autoregulation-related indices PRx and Mx was investigated. MATERIALS AND METHODS Thirty patients (aged 18-77 years, mean 53 ± 16 years) with severe cerebral diseases were studied. Cerebral blood flow velocity (CBFV), arterial blood pressure (ABP) and intracranial pressure (ICP) were repeatedly recorded. CA indices were calculated as the averaged correlation between CBFV and CPP (Mx) and between ABP and ICP (PRx). Positive index values indicated impairment of CA. RESULTS Six patients died in hospital. In this group both PRx and Mx were significantly higher than in the group of survivors (PRx: 0.41 ± 0.33 vs 0.09 ± 0.25; Mx: 0.28 ± 0.40 vs 0.03 ± 0.21; p = 0.01 and 0.04, respectively). PRx and Mx correlated significantly with Glasgow Outcome Scale (GOS) score (PRx: R = -0.40, p < 0.05; Mx: R = -0.54, p < 0.005). PRx was the only significant risk factor for mortality (p < 0.05, logistic regression). CONCLUSION Increased PRx and Mx were associated with risk of death in patients with severe cerebral diseases. The relationship with mortality was more pronounced in PRx, whereas Mx showed a better correlation with GOS score.
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MESH Headings
- Adolescent
- Adult
- Aged
- Brain Diseases/mortality
- Brain Diseases/physiopathology
- Brain Injuries, Traumatic/mortality
- Brain Injuries, Traumatic/physiopathology
- Cerebral Hemorrhage/mortality
- Cerebral Hemorrhage/physiopathology
- Cerebrovascular Circulation/physiology
- Encephalitis/mortality
- Encephalitis/physiopathology
- Female
- Homeostasis
- Humans
- Hypoxia, Brain/mortality
- Hypoxia, Brain/physiopathology
- Infarction, Middle Cerebral Artery/mortality
- Infarction, Middle Cerebral Artery/physiopathology
- Intracranial Hemorrhages/mortality
- Intracranial Hemorrhages/physiopathology
- Intracranial Pressure/physiology
- Male
- Middle Aged
- Middle Cerebral Artery/diagnostic imaging
- Middle Cerebral Artery/physiopathology
- Monitoring, Physiologic
- Prognosis
- Retrospective Studies
- Sinus Thrombosis, Intracranial/mortality
- Sinus Thrombosis, Intracranial/physiopathology
- Subarachnoid Hemorrhage/mortality
- Subarachnoid Hemorrhage/physiopathology
- Subarachnoid Hemorrhage, Traumatic/mortality
- Subarachnoid Hemorrhage, Traumatic/physiopathology
- Ultrasonography, Doppler, Transcranial
- Young Adult
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Affiliation(s)
- Bernhard Schmidt
- Department of Neurology, Chemnitz Medical Center, Dresdner Strasse 178, Chemnitz, 09131, Germany.
| | - Vesna Lezaic
- Department of Neurology, Chemnitz Medical Center, Dresdner Strasse 178, Chemnitz, 09131, Germany
| | - Marco Weinhold
- Department of Neurology, Chemnitz Medical Center, Dresdner Strasse 178, Chemnitz, 09131, Germany
| | - Ronny Plontke
- Department of Neurology, Chemnitz Medical Center, Dresdner Strasse 178, Chemnitz, 09131, Germany
| | - Jens Schwarze
- Department of Neurology, Chemnitz Medical Center, Dresdner Strasse 178, Chemnitz, 09131, Germany
| | - Jürgen Klingelhöfer
- Department of Neurology, Chemnitz Medical Center, Dresdner Strasse 178, Chemnitz, 09131, Germany
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29
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Budohoski KP, Czosnyka M, Kirkpatrick PJ. The Role of Monitoring Cerebral Autoregulation After Subarachnoid Hemorrhage. Neurosurgery 2015; 62 Suppl 1:180-4. [PMID: 26181941 DOI: 10.1227/neu.0000000000000808] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Karol P Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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30
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Fontana J, Wenz H, Schmieder K, Barth M. Impairment of Dynamic Pressure Autoregulation Precedes Clinical Deterioration after Aneurysmal Subarachnoid Hemorrhage. J Neuroimaging 2015; 26:339-45. [DOI: 10.1111/jon.12295] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/08/2015] [Revised: 07/03/2015] [Accepted: 08/06/2015] [Indexed: 11/30/2022] Open
Affiliation(s)
- Johann Fontana
- Department of Neurosurgery; Ruhr-University Bochum; Bochum Germany
| | - Holger Wenz
- Department of Neuroradiology; University Medicine Mannheim, Medical Faculty Mannheim of the University of Heidelberg; Germany
| | | | - Martin Barth
- Department of Neurosurgery; Ruhr-University Bochum; Bochum Germany
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31
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Dynamic Autoregulatory Response After Aneurysmal Subarachnoid Hemorrhage and Its Relation to Angiographic Vasospasm and Clinical Outcome. Neurocrit Care 2015; 23:355-63. [DOI: 10.1007/s12028-014-0104-7] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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32
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Tholance Y, Barcelos GK, Dailler F, Renaud B, Marinesco S, Perret-Liaudet A. Biochemical neuromonitoring of poor-grade aneurysmal subarachnoid hemorrhage: comparative analysis of metabolic events detected by cerebral microdialysis and by retrograde jugular vein catheterization. Neurol Res 2015; 37:578-87. [PMID: 25668478 DOI: 10.1179/1743132815y.0000000012] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Abstract
OBJECTIVES In severe aneurysmal subarachnoid hemorrhage (aSAH), pathological changes in cerebral energy metabolism can be detected either by local measurements using cerebral microdialysis (cMD) together with brain tissue oxygen probe or by global measurements of arterio-jugular difference performed with retrograde jugular vein catheter. Our main objective was to compare the two methods of detection and assess whether combining biomarkers from both procedures could improve outcome prediction, which has never been studied before. METHODS This study included 400 sets of paired arterial and jugular venous samples and 3138 brain microdialyzates obtained from 18 poor-grade aSAH patients. Using Glasgow outcome scale (GOS), neurochemical data from unfavorable (GOS 1-3) and favorable (GOS 4-5) outcome groups were compared. RESULTS The lactate/pyruvate ratio was found as the most sensitive marker for predicting unfavorable outcome (90%), although not specific. In contrast, hypoxic lactate events and those of metabolic ratio (MR) < 3.44, most frequently observed in the unfavorable outcome group than in the favorable one (13.9 vs 0.9% and 33.3 vs 3.75% respectively), were shown to be more specific biomarkers (86%) to predict unfavorable outcome, but less sensitive ( < 70%). The combination of these three biomarkers improved the accuracy of outcome prediction (sensitivity 90% and specificity 71%). DISCUSSION Both retrograde jugular venous catheterization (RJVC) and cMD contribute to monitor poor-grade aSAH patients. In this preliminary study, we show that these two techniques are complementary and their combination increases the accuracy of outcome prediction.
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33
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Wang X, Chen JX, Mao Q, Liu YH, You C. Relationship between intracranial pressure and aneurysmal subarachnoid hemorrhage grades. J Neurol Sci 2014; 346:284-7. [PMID: 25245175 DOI: 10.1016/j.jns.2014.09.011] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/08/2014] [Revised: 09/06/2014] [Accepted: 09/08/2014] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Intracranial pressure (ICP) is frequently elevated following aneurysmal subarachnoid hemorrhage (aSAH). In this prospective study, the factors associated with increased ICP and the relationship between ICP and the aSAH grade were evaluated. METHODS Consecutive patients with prospective aSAH were enrolled within 24h after disease onset. Clinical scoring, including the Hunt and Hess scale, the WFNS scale and the Fisher scale, was performed upon admission. Consciousness was evaluated based on the Glasgow Coma Scale, and the subarachnoid hemorrhage volume was determined according to a CT scan. Then, an ICP monitor was placed, and ICP was recorded. The relationship between ICP and the aSAH grade was examined using Spearman correlation coefficients. Additionally, some clinical characteristics of the patients, including age, sex, location and size of the aneurysm, hydrocephalus and rebleeding, were recorded and analyzed. RESULTS A total of 165 patients were enrolled in this study. Of these patients, 111 (67.2%) displayed elevated ICP (≥ 20 mm Hg). The patients who underwent intubation or who experienced rebleeding or hydrocephalus displayed an elevated ICP compared with those who did not (P = 0.002, P = 0.001 and P = 0.008, respectively). There was a positive linear correlation between ICP and both the Hunt and Hess grade and the WFNS grade (correlation coefficients of 0.731 and 0.761, respectively). The correlation between ICP and the Fisher grade was weak according to the correlation coefficient of only 0.093. CONCLUSION ICP following aSAH positively correlates with the patient's consciousness, but no relationship was detected between ICP and the subarachnoid hemorrhage volume.
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Affiliation(s)
- Xiang Wang
- Department of Neurosurgery, West China Hospital of Sichuan University, China
| | - Jin-xiu Chen
- Department of Radiology, Sichuan Cancer Hospital, China
| | - Qing Mao
- Department of Neurosurgery, West China Hospital of Sichuan University, China
| | - Yan-hui Liu
- Department of Neurosurgery, West China Hospital of Sichuan University, China
| | - Chao You
- Department of Neurosurgery, West China Hospital of Sichuan University, China.
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Dengler J, Frenzel C, Vajkoczy P, Horn P, Wolf S. The oxygen reactivity index and its relation to sensor technology in patients with severe brain lesions. Neurocrit Care 2014; 19:74-8. [PMID: 22396192 DOI: 10.1007/s12028-012-9686-0] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
BACKGROUND The oxygen reactivity index (ORx) has been introduced to assess the status of cerebral autoregulation after traumatic brain injury (TBI) or subarachnoid hemorrhage (SAH). Currently, there is some controversy about whether the ORx depends on the type of PbrO2-sensor technology used for its calculation. To examine if the probe technology does matter, we compared the ORx and the resulting optimal cerebral perfusion pressures (CPPopt) of simultaneously implanted Licox (CC1.SB, Integra Neuroscience, France) and Neurovent-PTO (Raumedic, Germany) probes in patients after aneurysmal SAH or severe TBI. METHODS Licox and Raumedic probes were implanted side by side in 11 patients after TBI or SAH. ORx and CPPopt were recorded continuously. The equivalence of both probes was examined using Bland-Altman analyses. RESULTS The mean difference in ORx was 0.1, with Licox producing higher values. The limits of agreement regarding ORx ranged from -0.6 to +0.7. When both probes' ORx values were compared in each patient, no specific pattern in their relationship was seen. The mean difference in CPPopt was 0 mmHg with limits of agreement between -16.5 and +16.4 mmHg. CONCLUSIONS Owing to the rather limited number of patients, we view the results of this study as preliminary. The main result is that Licox and Raumedic showed consistent differences in ORx and CPPopt. Therefore, ORx values of both probes cannot be interchanged and should not be viewed as equivalent. This should be taken into consideration when discussing ORx data generated by different PbrO2 probe types.
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Affiliation(s)
- Julius Dengler
- Department of Neurosurgery, Charité, Universitaetsmedizin Berlin, CVK, Augustenburger Platz 1, 13553, Berlin, Germany.
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Izzy S, Muehlschlegel S. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage and traumatic brain injury. Curr Treat Options Neurol 2013; 16:278. [PMID: 24347030 DOI: 10.1007/s11940-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OPINION STATEMENT Cerebral vasospasm (cVSP) consists of the vasoconstriction of large and small intracranial vessels which can lead to cerebral hypoperfusion, and in extreme cases, delayed ischemic deficits with stroke. While most commonly observed after aneurysmal subarachnoid hemorrhage (aSAH), cVSP can also occur after traumatic brain injury (TBI) as we have described in detail in this review. For the past decades, the research attention has focused on cVSP because of its association with delayed cerebral ischemia, which is the largest contributor of morbidity and mortality after aSAH. New discoveries in the cVSP pathophysiology involving multifactorial complex cascades and pathways pose new targets for therapeutic interventions in the prevention and treatment of cVSP. The goal of this review is to demonstrate the commonalities and differences in epidemiology and pathophysiology of both aSAH and TBI-associated cVSP, and highlight the more recently discovered pathways of cVSP. Finally, the latest cVSP surveillance methods and treatment options are illustrated.
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Affiliation(s)
- Saef Izzy
- Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
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Cerejo A, Silva PA, Vilarinho A, Dias C, Vaz R. Intraoperative brain oxygenation monitoring and vasospasm in aneurysmal subarachnoid hemorrhage. Neurol Res 2013; 34:181-6. [DOI: 10.1179/1743132811y.0000000064] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/31/2022]
Affiliation(s)
- A Cerejo
- Department of NeurosurgeryFaculty Of Medicine, HospitalS . João, Porto, Portugal
| | - P A Silva
- Department of NeurosurgeryFaculty Of Medicine, HospitalS . João, Porto, Portugal
| | - A Vilarinho
- Department of NeurosurgeryFaculty Of Medicine, HospitalS . João, Porto, Portugal
| | - C Dias
- Department of Intensive Care Hospital S. João, Porto, Portugal
| | - R Vaz
- Department of NeurosurgeryFaculty Of Medicine, HospitalS . João, Porto, Portugal
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Simultaneous measurement of deep tissue blood flow and oxygenation using noncontact diffuse correlation spectroscopy flow-oximeter. Sci Rep 2013; 3:1358. [PMID: 23446991 PMCID: PMC3584314 DOI: 10.1038/srep01358] [Citation(s) in RCA: 65] [Impact Index Per Article: 5.9] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/11/2012] [Accepted: 02/14/2013] [Indexed: 01/10/2023] Open
Abstract
We report a novel noncontact diffuse correlation spectroscopy flow-oximeter for simultaneous quantification of relative changes in tissue blood flow (rBF) and oxygenation (Δ[oxygenation]). The noncontact probe was compared against a contact probe in tissue-like phantoms and forearm muscles (n = 10), and the dynamic trends in both rBF and Δ[oxygenation] were found to be highly correlated. However, the magnitudes of Δ[oxygenation] measured by the two probes were significantly different. Monte Carlo simulations and phantom experiments revealed that the arm curvature resulted in a significant underestimation (~−20%) for the noncontact measurements in Δ[oxygenation], but not in rBF. Other factors that may cause the residual discrepancies between the contact and noncontact measurements were discussed, and further comparisons with other established technologies are needed to identify/quantify these factors. Our research paves the way for noncontact and simultaneous monitoring of blood flow and oxygenation in soft and vulnerable tissues without distorting tissue hemodynamics.
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Evidence-based cerebral vasospasm surveillance. Neurol Res Int 2013; 2013:256713. [PMID: 23862061 PMCID: PMC3686086 DOI: 10.1155/2013/256713] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/24/2012] [Accepted: 05/20/2013] [Indexed: 01/01/2023] Open
Abstract
Subarachnoid hemorrhage related to aneurysmal rupture (aSAH) carries significant morbidity and mortality, and its treatment is focused on preventing secondary injury. The most common—and devastating—complication is delayed cerebral ischemia resulting from vasospasm. In this paper, the authors review the various surveillance technologies available to detect cerebral vasospasm in the days following aSAH. First, evidence related to the most common modalities, including transcranial doppler ultrasonography and computed tomography, are reviewed. Continuous electroencephalography and older instruments such as positron emission tomography, xenon-enhanced CT, and single-photon emission computed tomography are also discussed. Invasive strategies including brain tissue oxygen monitoring, microdialysis, thermal diffusion, and jugular bulb oximetry are examined. Lastly, near-infrared spectroscopy, a recent addition to the field, is briefly reviewed. Each surveillance tool carries its own set of advantages and limitations, and the concomitant use of multiple modalities serves to improve diagnostic sensitivity and specificity.
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Abstract
The monitoring of intracranial pressure (ICP) is an important tool in medicine for its ability to portray the brain’s compliance status. The bedside monitor displays the ICP waveform and intermittent mean values to guide physicians in the management of patients, particularly those having sustained a traumatic brain injury. Researchers in the fields of engineering and physics have investigated various mathematical analysis techniques applicable to the waveform in order to extract additional diagnostic and prognostic information, although they largely remain limited to research applications. The purpose of this review is to present the current techniques used to monitor and interpret ICP and explore the potential of using advanced mathematical techniques to provide information about system perturbations from states of homeostasis. We discuss the limits of each proposed technique and we propose that nonlinear analysis could be a reliable approach to describe ICP signals over time, with the fractal dimension as a potential predictive clinically meaningful biomarker. Our goal is to stimulate translational research that can move modern analysis of ICP using these techniques into widespread practical use, and to investigate to the clinical utility of a tool capable of simplifying multiple variables obtained from various sensors.
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Affiliation(s)
- Antonio Di Ieva
- Department of Surgery, Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
- Injury Prevention Research Office, St. Michael’s Hospital, Toronto, ON, Canada
| | - Erika M. Schmitz
- Injury Prevention Research Office, St. Michael’s Hospital, Toronto, ON, Canada
| | - Michael D. Cusimano
- Department of Surgery, Division of Neurosurgery, St. Michael’s Hospital, University of Toronto, Toronto, ON, Canada
- Injury Prevention Research Office, St. Michael’s Hospital, Toronto, ON, Canada
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Pressure reactivity index correlates with metabolic dysfunction in a porcine model of intracerebral hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012. [PMID: 22327724 DOI: 10.1007/978-3-7091-0956-4_70] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
OBJECTIVE We correlated oxygen, flow, and pressure indices of cerebrovascular reactivity (CR) with extracellular cerebral metabolite concentrations in a porcine model of intracerebral hemorrhage (ICH). METHODS Continuous advanced multimodal monitoring including microdialysis, cerebral blood flow and P(br)O(2) probes were placed 1 cm in front of the coronal suture in the grey/white matter junction. Following a period of 1 h of monitoring, an autologous arterial ICH with defined volumes (3 mL) was induced. Pressure-, oxygen-, and flow-related autoregulation indices (PRx, ORx, and FRx) were simultaneously calculated and correlated hourly with extracellular cerebral metabolites, including glucose, lactate, pyruvate, and glutamate. RESULTS Seventeen swine were monitored on average 12 continuous hours per animal. FRx correlated highly with ORx (0.96, P = <0.001), but values of both FRx and ORx > 0.2 did not correlate with any microdialysis metabolite. Values of PRx > 0.2 correlated highly (0.65, P < 0.001) with the lactate/pyruvate ratio, values of PRx > 0.3 correlated with glutamate (0.67, P < 0.05), the lactate/pyruvate ratio (0.60, P < 0.01), and P(br)O(2) (-0.65, P < 0.01). CONCLUSIONS We found evidence for impaired CR in a porcine model of ICH. The findings suggest that, among other parameters of CR, positive PRx coefficients have the highest significance and could be associated with microdialysis alterations during hypoxic events.
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Eide PK, Sorteberg A, Bentsen G, Marthinsen PB, Stubhaug A, Sorteberg W. Pressure-derived versus pressure wave amplitude–derived indices of cerebrovascular pressure reactivity in relation to early clinical state and 12-month outcome following aneurysmal subarachnoid hemorrhage. J Neurosurg 2012; 116:961-71. [DOI: 10.3171/2012.1.jns111313] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Object
Indices of cerebrovascular pressure reactivity (CPR) represent surrogate markers of cerebral autoregulation. Given that intracranial pressure (ICP) wave amplitude–guided management, as compared with static ICP-guided management, improves outcome following aneurysmal subarachnoid hemorrhage (SAH), indices of CPR derived from pressure wave amplitudes should be further explored. This study was undertaken to investigate the value of CPR indices derived from static ICP–arterial blood pressure (ABP) values (pressure reactivity index [PRx]) versus ICP-ABP wave amplitudes (ICP-ABP wave amplitude correlation [IAAC]) in relation to the early clinical state and 12-month outcome in patients with aneurysmal SAH.
Methods
The authors conducted a single-center clinical trial enrolling patients with aneurysmal SAH. The CPR indices of PRx and IAAC of Week 1 after hemorrhage were related to the early clinical state (Glasgow Coma Scale [GCS] score) and 12-month outcome (modified Rankin Scale score).
Results
Ninety-four patients were included in the study. The IAAC, but not the PRx, increased with decreasing GCS score; that is, the higher the IAAC, the worse the clinical state. The PRx could differentiate between survivors and nonsurvivors only, whereas the IAAC clearly distinguished the groups “independent,” “dependent,” and “dead.” In patients with an average IAAC ≥ 0.2, mortality was approximately 3-fold higher than in those with an IAAC < 0.2.
Conclusions
The IAAC, which is based on single ICP-ABP wave identification, relates significantly to the early clinical state and 12-month outcome following aneurysmal SAH. Impaired cerebrovascular pressure regulation during the 1st week after a bleed relates to a worse outcome. Clinical trial registration no.: NCT00248690.
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Affiliation(s)
- Per Kristian Eide
- 1Departments of Neurosurgery,
- 4Faculty of Medicine, University of Oslo, Norway
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Is P(br)O (2) pressure reactivity index (ORx) dependent on the type of oxygen probe? An in vivo study. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012. [PMID: 22327687 DOI: 10.1007/978-3-7091-0956-4_33] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register]
Abstract
OBJECTIVE To evaluate if ORx is dependent on the type of brain tissue O(2) (P(br)O(2)) probe in an in vivo setting. METHODS In eight German landrace pigs two types of probes were implanted simultaneously in the same cerebral hemisphere. All pigs underwent hepatectomy and received neuromonitoring until death. A LICOX(®) probe CCI.S, representing a Clarke type electrode, was compared with a Raumedic Neurovent PTO, representing an optode. Data were sampled at 50 Hz. Average values were calculated every 30 s. Cerebral perfusion pressure (CPP) was averaged over 30 s. ORx was calculated for each probe. To increase the signal to noise ratio of the ORx, the ORx values, which had been assessed every minute, were averaged over 1 h. RESULTS The overall measurement time was 145.1 h (8,703 data pairs). Despite a mean difference of 6.2 mmHg (p < 0.0001) in the measured values of P(br)O(2), the mean ORx(licox) was 0.139, mean ORx(raumedic) 0.146 (p = 0.2098). Correlation coefficient of ORx values assessed every minute and every hour was 0.52 and 0.58 respectively. CONCLUSION Despite this significant difference in absolute values of P(br)O(2) the derived mean ORx values were not different. Similar to the established Licox system, the Raumedic system seems to enable a valid ORx recording.
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Sandsmark DK, Kumar MA, Park S, Levine JM. Multimodal monitoring in subarachnoid hemorrhage. Stroke 2012; 43:1440-5. [PMID: 22426466 DOI: 10.1161/strokeaha.111.639906] [Citation(s) in RCA: 26] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Affiliation(s)
- Danielle K Sandsmark
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, PA 19104, USA
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Woitzik J, Dreier JP, Hecht N, Fiss I, Sandow N, Major S, Winkler M, Dahlem YA, Manville J, Diepers M, Muench E, Kasuya H, Schmiedek P, Vajkoczy P. Delayed cerebral ischemia and spreading depolarization in absence of angiographic vasospasm after subarachnoid hemorrhage. J Cereb Blood Flow Metab 2012; 32:203-12. [PMID: 22146193 PMCID: PMC3272613 DOI: 10.1038/jcbfm.2011.169] [Citation(s) in RCA: 144] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/13/2023]
Abstract
It has been hypothesized that vasospasm is the prime mechanism of delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). Recently, it was found that clusters of spreading depolarizations (SDs) are associated with DCI. Surgical placement of nicardipine prolonged-release implants (NPRIs) was shown to strongly attenuate vasospasm. In the present study, we tested whether SDs and DCI are abolished when vasospasm is reduced or abolished by NPRIs. After aneurysm clipping, 10 NPRIs were placed next to the proximal intracranial vessels. The SDs were recorded using a subdural electrode strip. Proximal vasospasm was assessed by digital subtraction angiography (DSA). 534 SDs were recorded in 10 of 13 patients (77%). Digital subtraction angiography revealed no vasospasm in 8 of 13 patients (62%) and only mild or moderate vasospasm in the remaining. Five patients developed DCI associated with clusters of SD despite the absence of angiographic vasospasm in three of those patients. The number of SDs correlated significantly with the development of DCI. This may explain why reduction of angiographic vasospasm alone has not been sufficient to improve outcome in some clinical studies.
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Affiliation(s)
- Johannes Woitzik
- Department of Neurosurgery, Charité-Universitätsmedizin Berlin, Berlin, Germany.
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Abstract
Several non-invasive and invasive modalities have been used to monitor patients for cerebral ischemia after subarachnoid hemorrhage. A literature search was performed to identify original research studies testing monitors that may be used in addition to the standard measures of brain function and cerebral blood flow. Fifty observational studies were identified that evaluated the role of electroencephalography, brain tissue oxygenation monitoring, cerebral microdialysis, thermal diffusion flowmetry, or near-infrared spectroscopy in patients after subarachnoid hemorrhage.
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Barth M, Moratin B, Dostal M, Kalenka A, Scharf J, Schmieder K. Correlation of clinical outcome and angiographic vasospasm with the dynamic autoregulatory response after aneurysmal subarachnoid hemorrhage. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012; 114:157-160. [PMID: 22327683 DOI: 10.1007/978-3-7091-0956-4_29] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/31/2023]
Abstract
BACKGROUND A certain correlation between unfavorable clinical outcome, incidence of vasospasm, and impaired pressure autoregulation in patients following aneurysmal subarachnoid hemorrhage (aSAH) has been suggested. However, determination of vasospasm is inaccurate and the measurement technique of cerebral vasoreactivity seems not to have been sufficiently validated. Therefore, a correlation of clinical outcome and the extent of angiographic VS was performed using an established autoregulation test. MATERIAL AND METHODS Proximal and global angiographic vasospasm (pVS, gVS) were determined in bilateral M1 segments. Dynamic tests of pressure autoregulation were performed 1 day before and after, and on the day of angiography using Aaslid's thigh leg cuff test. Patient outcome was assessed using the Extended Glasgow Outcome Scale (GOSE). KEY RESULTS Complete datasets were available for 22 patients. Mean autoregulatory indices (ARI) around the day of angiography were 3.9 ± 2.3. Proximal mean reduction of vessel diameter was -23.3% ± 9.1%. Global vasospasm was not present in 10 hemispheres, mild in 15, moderate in 15, and severe in 4. Hemispheric ARI values and angiographic data showed a significant correlation (pVS -0.382, p = 0.015; gVS -0.477, p = 0.002). The degree of angiographic vasospasm and low ARI values correlated significantly with an unfavorable outcome (0.677, p = 0.001). CONCLUSION Incidence of angiographic vasospasm and impaired clinical outcome seems to be related to impaired pressure autoregulation following aSAH.
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Affiliation(s)
- Martin Barth
- Department of Neurosurgery, University Medicine Mannheim, Medical Faculty Mannheim of the Karl-Ruprecht-University of Heidelberg, Mannheim, Germany.
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Morgalla MH, Haas R, Grözinger G, Thiel C, Thiel K, Schuhmann MU, Schenk M. Experimental comparison of the measurement accuracy of the Licox(®) and Raumedic (®) Neurovent-PTO brain tissue oxygen monitors. ACTA NEUROCHIRURGICA. SUPPLEMENT 2012; 114:169-72. [PMID: 22327686 DOI: 10.1007/978-3-7091-0956-4_32] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
BACKGROUND Only a few experimental reports are available on the direct comparison of Licox(®) and Raumedic(®)-Neurovent-PTO brain tissue oxygen pressure (P(br)O(2)) monitors. We compared the two systems regarding their measurement properties under experimental in vitro and in vivo conditions. MATERIALS AND METHODS Eight Licox(®) and Raumedic(®) Neurovent-PTO(®) sensors were tested for 10 min at 37°C, atmospheric pressure, at an oxygen content of 0% and 100% before and after the in vivo test. The same probes were implanted in German landrace pigs, which underwent hepatectomy. The mean P(br)O(2) values were recorded every minute. An O(2) challenge with inhalation of 100% O(2) for 10 min was performed 2 h post-abdominal surgery. RESULTS At 0% O(2) content values varied from 0.2 to 7 mmHg, at 100% O(2) content from 130 to 165 mmHg. No difference between probes was found. In vivo tests: Raumedic® showed higher P(br)O(2) values (mean +6.3 mmHg, p < 0.0001) compared with Licox®. During O(2) challenge, both probes responded similarly; however, Raumedic(®) had a 10% higher response amplitude (p < 0.005). After explantation there was again no difference between the two sensors. CONCLUSION Raumedic(®) sensors measured higher P(br)O(2) values. There was no significant difference regarding overall measurement of in vitro accuracy between the two probes, which proved to be robust when used consecutively for longer periods and in different environments.
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Affiliation(s)
- Matthias H Morgalla
- Department of Neurosurgery, Eberhard Karls University Hospital, Tübingen, Germany.
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Hecht N, Fiss I, Wolf S, Barth M, Vajkoczy P, Woitzik J. Modified flow- and oxygen-related autoregulation indices for continuous monitoring of cerebral autoregulation. J Neurosci Methods 2011; 201:399-403. [DOI: 10.1016/j.jneumeth.2011.08.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2011] [Revised: 07/11/2011] [Accepted: 08/02/2011] [Indexed: 02/04/2023]
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Helbok R, Ko SB, Schmidt JM, Kurtz P, Fernandez L, Choi HA, Connolly ES, Lee K, Badjatia N, Mayer SA, Claassen J. Global cerebral edema and brain metabolism after subarachnoid hemorrhage. Stroke 2011; 42:1534-9. [PMID: 21493918 DOI: 10.1161/strokeaha.110.604488] [Citation(s) in RCA: 48] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE Global cerebral edema is common among patients with poor-grade subarachnoid hemorrhage and is associated with poor outcome. Currently no targeted therapy exists largely due to an incomplete understanding of the underlying mechanisms. METHODS This is a prospective observational study including 39 consecutive patients with poor-grade subarachnoid hemorrhage with multimodal neuromonitoring. Levels of microdialysate lactate-pyruvate ratio, episodes of cerebral metabolic crisis (lactate-pyruvate ratio >40 and brain glucose <0.7 mmol/L), brain tissue oxygen tension, cerebral perfusion pressure, and transcranial Doppler sonography flow velocities were analyzed. RESULTS Median age was 54 years (range, 45 to 61 years) and 62% were female. Patients with global cerebral edema on admission (n=24 [62%]) had a higher incidence of metabolic crisis in the first 12 hours of monitoring (n=15 [15% versus 2%], P<0.05) and during the total time of neuromonitoring (20% versus 3%, P<0.001) when compared to those without global cerebral edema. There was no difference in brain tissue oxygen tension or cerebral perfusion pressure between the groups; however, in patients with global cerebral edema, a higher cerebral perfusion pressure was associated with lower lactate-pyruvate ratio (P<0.05). Episodes of metabolic crisis were associated with poor outcome (modified Rankin Scale score 5 or 6, P<0.05). CONCLUSIONS In patients with poor-grade subarachnoid hemorrhage, global cerebral edema is associated with early brain metabolic distress.
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Affiliation(s)
- Raimund Helbok
- Division of Critical Care Neurology, Department of Neurology, Columbia University Medical Center, New York, NY 10032, USA
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