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Islam A, Froese L, Bergmann T, Gomez A, Sainbhi AS, Vakitbilir N, Stein KY, Marquez I, Ibrahim Y, Zeiler FA. Continuous monitoring methods of cerebral compliance and compensatory reserve: a scoping review of human literature. Physiol Meas 2024; 45:06TR01. [PMID: 38776946 DOI: 10.1088/1361-6579/ad4f4a] [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: 01/11/2024] [Accepted: 05/22/2024] [Indexed: 05/25/2024]
Abstract
Objective.Continuous monitoring of cerebrospinal compliance (CC)/cerebrospinal compensatory reserve (CCR) is crucial for timely interventions and preventing more substantial deterioration in the context of acute neural injury, as it enables the early detection of abnormalities in intracranial pressure (ICP). However, to date, the literature on continuous CC/CCR monitoring is scattered and occasionally challenging to consolidate.Approach.We subsequently conducted a systematic scoping review of the human literature to highlight the available continuous CC/CCR monitoring methods.Main results.This systematic review incorporated a total number of 76 studies, covering diverse patient types and focusing on three primary continuous CC or CCR monitoring metrics and methods-Moving Pearson's correlation between ICP pulse amplitude waveform and ICP, referred to as RAP, the Spiegelberg Compliance Monitor, changes in cerebral blood flow velocity with respect to the alternation of ICP measured through transcranial doppler (TCD), changes in centroid metric, high frequency centroid (HFC) or higher harmonics centroid (HHC), and the P2/P1 ratio which are the distinct peaks of ICP pulse wave. The majority of the studies in this review encompassed RAP metric analysis (n= 43), followed by Spiegelberg Compliance Monitor (n= 11), TCD studies (n= 9), studies on the HFC/HHC (n= 5), and studies on the P2/P1 ratio studies (n= 6). These studies predominantly involved acute traumatic neural injury (i.e. Traumatic Brain Injury) patients and those with hydrocephalus. RAP is the most extensively studied of the five focused methods and exhibits diverse applications. However, most papers lack clarification on its clinical applicability, a circumstance that is similarly observed for the other methods.Significance.Future directions involve exploring RAP patterns and identifying characteristics and artifacts, investigating neuroimaging correlations with continuous CC/CCR and integrating machine learning, holding promise for simplifying CC/CCR determination. These approaches should aim to enhance the precision and accuracy of the metric, making it applicable in clinical practice.
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Affiliation(s)
- Abrar Islam
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Tobias Bergmann
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Izabella Marquez
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
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Riparbelli AC, Capion T, Møller K, Mathiesen TI, Olsen MH, Forsse A. Critical ICP thresholds in relation to outcome: Is 22 mmHg really the answer? Acta Neurochir (Wien) 2024; 166:63. [PMID: 38315234 PMCID: PMC10844356 DOI: 10.1007/s00701-024-05929-y] [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: 10/18/2023] [Accepted: 01/11/2024] [Indexed: 02/07/2024]
Abstract
PURPOSE Intensive care for patients with traumatic brain injury (TBI) aims, among other tasks, at avoiding high intracranial pressure (ICP), which is perceived to worsen motor and cognitive deficits and increase mortality. International recommendations for threshold values for ICP were increased from 20 to 22 mmHg in 2016 following the findings in a study by Sorrentino et al., which were based on an observational study of patients with TBI of averaged ICP values. We aimed to reproduce their approach and validate the findings in a separate cohort. METHODS Three hundred thirty-one patients with TBI were included and categorised according to survival/death and favourable/unfavourable outcome at 6 months (based on Glasgow Outcome Score-Extended of 6-8 and 1-5, respectively). Repeated chi-square tests of survival and death (or favourable and unfavourable outcome) vs. high and low ICP were conducted with discrimination between high and low ICP sets at increasing values (integers) between 10 and 35 mmHg, using the average ICP for the entire monitoring period. The ICP limit returning the highest chi-square score was assumed to be the threshold with best discriminative ability. This approach was repeated after stratification by sex, age, and initial Glasgow Coma Score (GCS). RESULTS An ICP limit of 18 mmHg was found for both mortality and unfavourable outcome for the entire cohort. The female and the low GCS subgroups both had threshold values of 18 mmHg; for all other subgroups, the threshold varied between 16 and 30 mmHg. According to a multiple logistic regression analysis, age, initial GCS, and average ICP are independently associated with mortality and outcome. CONCLUSIONS Using identical methods and closely comparable cohorts, the critical thresholds for ICP found in the study by Sorrentino et al. could not be reproduced.
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Affiliation(s)
- Agnes C Riparbelli
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark.
| | - Tenna Capion
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Kirsten Møller
- Department of Neuroanesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences SUND, University of Copenhagen, Copenhagen, Denmark
| | - Tiit I Mathiesen
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences SUND, University of Copenhagen, Copenhagen, Denmark
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Markus H Olsen
- Department of Neuroanesthesiology, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
| | - Axel Forsse
- Department of Neurosurgery, Copenhagen University Hospital - Rigshospitalet, Copenhagen, Denmark
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Che Y, Lu T, Wang T, Zhao H, Song X, Zhan Q, Zhang C, Pan H, Yang K, Wang B. A Meta-analysis of the Clinical Efficacy of the Head-of-Bed Elevation for Patients With Acquired Brain Injury. J Neurosci Nurs 2023; 55:91-96. [PMID: 37094377 DOI: 10.1097/jnn.0000000000000703] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/26/2023]
Abstract
ABSTRACT BACKGROUND: Acquired brain injury is caused by traumatic or nontraumatic factors and causes changes in cognition. Several reviews have described the influence of the head-of-bed (HOB) elevation on clinical indexes such as intracranial pressure (ICP) and cerebral perfusion pressure (CPP). However, the conclusions were inconsistent. Therefore, we aimed to evaluate the effects of HOB elevation in the care of the patients with ABI. METHODS: Two researchers independently screened the literature and extracted data. We searched PubMed, EMBASE, the Cochrane Library, Web of Science, and the Chinese Biological Literature Database to collect eligible randomized controlled trials published after September 2021. Reporting quality and methodological quality of the included studies were assessed by using the Preferred Reporting Items for Systematic Reviews and Meta-analysis and the Cochrane risk-of-bias tool. RESULTS : Eight studies were included in the meta-analysis. The results showed that, compared with the flat position, HOB elevation of 30° or 45° can significantly reduce ICP (mean difference [MD], -2.40 mm Hg; 95% confidence interval [CI], -3.19 to -1.61; P < .00001). However, there were no statistical differences in CPP (MD, -1.09; 95% CI, -3.93 to 1.75; P = .45), degree of disability at 90 days (relative risk, 1.01; 95% CI, 0.94-1.08; P = .83), and mean arterial pressure (MD, -0.44; 95% CI, -10.27 to 9.93; P = .93). CONCLUSION: Head-of-bed elevation of 30° can reduce ICP and maintain CPP, and may be an effective noninvasive nursing practice for the prognosis and rehabilitation of ABI patients. Owing to the lack of high-quality, large-sample randomized controlled trials, more rigorous trials are needed to support this conclusion.
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Omerhodzic I, Dzurlic A, Rovcanin B, Rotim K, Hadzimehmedagic A, Ahmetspahic A, Zvizdic Z, Granov N, Suljic E. Hinge craniotomy as an alternative technique for patients with refractory intracranial hypertension. BRAIN & SPINE 2023; 3:101758. [PMID: 37383443 PMCID: PMC10293230 DOI: 10.1016/j.bas.2023.101758] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 01/26/2023] [Revised: 05/04/2023] [Accepted: 05/10/2023] [Indexed: 06/30/2023]
Abstract
Introduction Decompressive craniectomy (DC) can save brain tissue, but unfortunately it has many limitations and complications. Hinge craniotomy (HC), as less aggressive method seems to be adequate alternative not only to DC but also to conservative treatment. Research question Presentation of the results of modified surgical techniques of cranial decompression and comparing with more and less aggressive medical options. Material and methods A prospective clinical study was conducted during 86 months. Comatose patients who suffered refractory intracranial hypertension (RIH) were treated. Altogether, 137 patients have been evaluated. The final outcome of all patients in the study was evaluated after 6 months. Results Both surgical options resulted in adequate control of intracranial pressure (ICP). HC method was shown to have the lowest probability of worsening from a prior state of relative stability. Discussion and conclusion There was no statistically significant difference between methods to treatment of DC or HC, meaning the final outcome of patients treated in any manner. There was similar rate of early and late complications.
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Affiliation(s)
- Ibrahim Omerhodzic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Almir Dzurlic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Bekir Rovcanin
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Kresimir Rotim
- Department of Neurosurgery, Clinical Hospital Center Sisters of Mercy, Zagreb, Croatia
| | - Amel Hadzimehmedagic
- Department of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Adi Ahmetspahic
- Department of Neurosurgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Zlatan Zvizdic
- Department of Pediatric Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Nermir Granov
- Department of Cardiovascular Surgery, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
| | - Enra Suljic
- Department of Neurology, Clinical Center University of Sarajevo, Sarajevo, Bosnia and Herzegovina
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El-Swaify ST, Kamel M, Ali SH, Bahaa B, Refaat MA, Amir A, Abdelrazek A, Beshay PW, Basha AKMM. Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges. Surg Neurol Int 2022; 13:431. [DOI: 10.25259/sni_609_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).
Methods:
We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.
Results:
This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.
Conclusion:
Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.
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Affiliation(s)
- Seif Tarek El-Swaify
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Menna Kamel
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Ali
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassem Bahaa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman Amir
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Pavly Wagih Beshay
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
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Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
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Laws JC, Jordan LC, Pagano LM, Wellons JC, Wolf MS. Multimodal Neurologic Monitoring in Children With Acute Brain Injury. Pediatr Neurol 2022; 129:62-71. [PMID: 35240364 PMCID: PMC8940706 DOI: 10.1016/j.pediatrneurol.2022.01.006] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/16/2021] [Revised: 01/04/2022] [Accepted: 01/25/2022] [Indexed: 12/26/2022]
Abstract
Children with acute neurologic illness are at high risk of mortality and long-term neurologic disability. Severe traumatic brain injury, cardiac arrest, stroke, and central nervous system infection are often complicated by cerebral hypoxia, hypoperfusion, and edema, leading to secondary neurologic injury and worse outcome. Owing to the paucity of targeted neuroprotective therapies for these conditions, management emphasizes close physiologic monitoring and supportive care. In this review, we will discuss advanced neurologic monitoring strategies in pediatric acute neurologic illness, emphasizing the physiologic concepts underlying each tool. We will also highlight recent innovations including novel monitoring modalities, and the application of neurologic monitoring in critically ill patients at risk of developing neurologic sequelae.
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Affiliation(s)
- Jennifer C Laws
- Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lori C Jordan
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Lindsay M Pagano
- Division of Pediatric Neurology, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee
| | - John C Wellons
- Division of Pediatric Neurological Surgery, Department of Neurological Surgery, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Michael S Wolf
- Division of Pediatric Critical Care Medicine, Department of Pediatrics, Vanderbilt University Medical Center, Nashville, Tennessee.
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Balakrishnan S, Naik S, Chakrabarti D, Konar S, Sriganesh K. Effect of Respiratory Physiological Changes on Optic Nerve Sheath Diameter and Cerebral Oxygen Saturation in Patients With Acute Traumatic Brain Injury. J Neurosurg Anesthesiol 2022; 34:e52-e56. [PMID: 32555065 DOI: 10.1097/ana.0000000000000706] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2020] [Accepted: 05/17/2020] [Indexed: 11/26/2022]
Abstract
BACKGROUND Severe traumatic brain injury (TBI) results in raised intracranial pressure (ICP). Ultrasonographic measurement of the optic nerve sheath diameter (ONSD) is a noninvasive method for the assessment of raised ICP. Manipulation of positive end-expiratory pressure (PEEP) and end-tidal carbon dioxide (ETCO2) are often used to optimize ICP and improve oxygenation in TBI patients. This study evaluated the effects of PEEP and ETCO2 on ONSD and regional cerebral oxygen saturation (rScO2) in patients with acute TBI. METHODS A total of 14 patients (11 males) aged older than 18 years with acute severe TBI were included in this study. ONSD and rScO2 were assessed before and after changes in PEEP from 5 to 10 cm H2O and in ETCO2 from 40 to 30 mm Hg on both pathologic and nonpathologic sides. RESULTS Increasing PEEP and reducing ETCO2 resulted in changes in ONSD and rScO2 on both pathologic and nonpathologic sides. On the pathologic side, ONSD and rScO2 were highest with a PEEP of 10 cm H2O:ETCO2 40 mm Hg combination and lowest with PEEP of 5 cm H2O:ETCO2 30 mm Hg (ONSD 5.24±0.49 vs. 4.27±0.36 mm, P<0.001; rScO2 70.7±9.91% vs. 66.3±9.75%, P<0.001); both PEEP and ETCO2 had significant effects on ONSD and rScO2 (P<0.001). On the nonpathologic side, ONSD and rScO2 were highest and lowest with PEEP of 10 cm H2O:ETCO2 40 mm Hg and PEEP of 5 cm H2O:ETCO2 30 mm Hg combinations, respectively (ONSD: 4.93±0.46 vs. 4.02±0.40 mm, P<0.001; rScO2: 74.77±8.30% vs. 70.69±8.12%, P<0.001). ETCO2 had a significant effect on rScO2 (P<0.001), but the impact of PEEP on rScO2 was not statistically significant (P=0.05). CONCLUSION Increasing PEEP resulted in significant increases in ONSD and rScO2, whereas reducing ETCO2 significantly decreased ONSD and rScO2.
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Affiliation(s)
- Sweatha Balakrishnan
- National Institute of Mental Health and Neurosciences, Bengaluru, Karnataka, India
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10
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Batson C, Froese L, Gomez A, Sainbhi AS, Stein KY, Alizadeh A, Zeiler FA. Impact of Age and Biological Sex on Cerebrovascular Reactivity in Adult Moderate/Severe Traumatic Brain Injury: An Exploratory Analysis. Neurotrauma Rep 2021; 2:488-501. [PMID: 34901944 PMCID: PMC8655816 DOI: 10.1089/neur.2021.0039] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/16/2023] Open
Abstract
Age and biological sex are two potential important modifiers of cerebrovascular reactivity post-traumatic brain injury (TBI) requiring close evaluation for potential subgroup responses. The goal of this study was to provide a preliminary exploratory analysis of the impact of age and biological sex on measures of cerebrovascular function in moderate/severe TBI. Forty-nine patients from the prospectively maintained TBI database at the University of Manitoba with archived high-frequency digital cerebral physiology were evaluated. Cerebrovascular reactivity indices were derived as follows: PRx (correlation between intracranial pressure [ICP] and mean arterial pressure [MAP]), PAx (correlation between pulse amplitude of ICP [AMP] and MAP), and RAC (correlation between AMP and cerebral perfusion pressure [CPP]). Time above clinically significant thresholds for each index was calculated over different periods of the acute intensive care unit stay. The association between PRx, PAx, and RAC measures with age was assessed using linear regression, and an age trichotomization scheme (<40, 40-60, >60) using Kruskal-Wallis testing. Similarly, association with biological sex was tested using Mann-Whitney U testing. Biological sex did not demonstrate an impact on any measures of cerebrovascular reactivity. Linear regression between age and PAx and RAC demonstrated a statistically significant positive linear relationship. Median PAx and RAC measures between trichotomized age categories demonstrated statistically significant increases with advancing age. The PRx failed to demonstrate any statistically significant relationship with age in this cohort, suggesting that in elderly patients with controlled ICP, PAx and RAC may be better metrics for detecting impaired cerebrovascular reactivity. Biological sex appears to not be associated with differences in cerebrovascular reactivity in this cohort. The PRx performed the worst in detecting impaired cerebrovascular reactivity in those with advanced age, where PAx and RAC appear to have excelled. Future work is required to validate these findings and explore the utility of different cerebrovascular reactivity indices.
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Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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11
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Fedriga M, Czigler A, Nasr N, Zeiler FA, Park S, Donnelly J, Papaioannou V, Frisvold SK, Wolf S, Rasulo F, Sykora M, Smielewski P, Czosnyka M. Autonomic Nervous System Activity during Refractory Rise in Intracranial Pressure. J Neurotrauma 2021; 38:1662-1669. [PMID: 33280491 PMCID: PMC8336253 DOI: 10.1089/neu.2020.7091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Refractory intracranial hypertension (RIH) is a dramatic increase in intracranial pressure (ICP) that cannot be controlled by treatment. Recent reports suggest that the autonomic nervous system (ANS) activity may be altered during changes in ICP. Our study aimed to assess ANS activity during RIH and the causal relationship between rising in ICP and autonomic activity. We reviewed retrospectively 24 multicenter (Cambridge, Tromso, Berlin) patients in whom RIH developed as a pre-terminal event after acute brain injury (ABI). They were monitored with ICP, arterial blood pressure (ABP), and electrocardiography (ECG) using ICM+ software. Parameters reflecting autonomic activity were computed in time and frequency domain through the measurement of heart rate variability (HRV) and baroreflex sensitivity (BRS). Our results demonstrated that a rise in ICP was associated to a significant rise in HRV and BRS with a higher significance level in the high-frequency HRV (p < 0.001). This increase was followed by a significant decrease in HRV and BRS above the upper-breakpoint of ICP where ICP pulse-amplitude starts to decrease whereas the mean ICP continues to rise. Temporality measured with a Granger test suggests a causal relationship from ICP to ANS. The above results suggest that a rise in ICP interacts with ANS activity, mainly interfacing with the parasympathetic-system. The ANS seems to react to the rise in ICP with a response possibly focused on maintaining the cerebrovascular homeostasis. This happens until the critical threshold of ICP is reached above which the ANS variables collapse, probably because of low perfusion of the brain and the central autonomic network.
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Affiliation(s)
- Marta Fedriga
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Andras Czigler
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs, Pecs, Hungary
| | - Nathalie Nasr
- Unitè de Neurologie Vasculaire, CHU de Toulouse, Universitè de Toulouse, Toulouse, France
| | - Frederick. A. Zeiler
- Department of Surgery, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Soojin Park
- Department of Neurology, Division of Hospitalist and Critical Care Neurology, Columbia University, New York, New York, USA
| | - Joseph Donnelly
- Department of Anaesthesiology, University of Auckland, Aukland, New Zealand
| | - Vasilios Papaioannou
- University Hospital of Alexandroupolis, Intensive Care Unit, Democritus University of Thrace, Alexandroupolis, Greece
| | - Shirin K Frisvold
- Department of Intensive Care, University Hospital of North Norway, UiT The Arctic University of Norway, Tromso, Norway
| | - Stephan Wolf
- Department of Neurosurgery, Charite Hospital, Berlin, Germany
| | - Frank Rasulo
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Marek Sykora
- Department of Neurology, St. John's Hospital Vienna, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Smielewski
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
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12
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How do we identify the crashing traumatic brain injury patient - the neurosurgeon's view. Curr Opin Crit Care 2021; 27:87-94. [PMID: 33395087 DOI: 10.1097/mcc.0000000000000799] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023]
Abstract
PURPOSE OF REVIEW To provide an overview on recent advances in the field of assessment and monitoring of patients with severe traumatic brain injury (sTBI) in neurocritical care from a neurosurgical point of view. RECENT FINDINGS In high-income countries, monitoring of patients with sTBI heavily relies on multimodal neurocritical parameters, nonetheless clinical assessment still has a solid role in decision-making. There are guidelines and consensus-based treatment algorithms that can be employed in both absence and presence of multimodal monitoring in the management of patients with sTBI. Additionally, novel dynamic monitoring options and machine learning-based prognostic models are introduced. Currently, the acute management and treatment of secondary injury/insults is focused on dealing with the objective evident pathology. An ongoing paradigm shift is emerging towards more proactive treatment of neuroworsening as soon as premonitory signs of deterioration are detected. SUMMARY Based on the current evidence, serial clinical assessment, neuroimaging, intracranial and cerebral perfusion pressure and brain tissue oxygen monitoring are key components of sTBI care. Clinical assessment has a crucial role in identifying the crashing patient with sTBI, especially from a neurosurgical standpoint. Multimodal monitoring and clinical assessment should be seen as complementary evaluation methods that support one another.
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Donnelly J, Zeiler FA, Güiza F, Beqiri E, Mitchell SJ, Aries MJ, Czosnyka M, Smielewski P. Visualization of Intracranial Pressure Insults After Severe Traumatic Brain Injury: Influence of Individualized Limits of Reactivity. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:7-10. [PMID: 33839808 DOI: 10.1007/978-3-030-59436-7_2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cerebral perfusion pressure (CPP) lower limits of reactivity can be determined almost continuously after severe traumatic brain injury (TBI), and deviation below the lower limit carries important prognostic information. In this study, we used a recently derived coloured contour method for visualizing intracranial pressure (ICP) insults to describe the influence of having a CPP above the CPP lower limits of reactivity after severe TBI. In a cohort of 729 patients, we examined the relationship between ICP insults and the 6-month Glasgow Outcome Scale score, using colour-coded plots, as described previously. We then assessed this relationship when ICP insults were above or below the CPP lower limit of reactivity. We found a curvilinear relationship whereby even prolonged durations of low-intensity ICP insults were not associated with poor outcomes but short durations of high-intensity insults were. When only ICP insults with a CPP below the CPP lower limit of reactivity were considered, a much lower intensity of ICP insults could be tolerated. A CPP above the lower limits of reactivity exerts a protective effect, whereas a CPP below the lower reactivity limits renders the patient vulnerable to increased morbidity from intracranial hypertension.
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Affiliation(s)
- Joseph Donnelly
- Academic Neurosurgery, University of Cambridge, Cambridge, UK.
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Fabian Güiza
- Intensive Care Medicine, KU Leuven, Leuven, Belgium
| | - Erta Beqiri
- Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Simon J Mitchell
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Marcel J Aries
- Department of Intensive Care, University of Maastricht, Maastricht, The Netherlands
| | - Marek Czosnyka
- Academic Neurosurgery, University of Cambridge, Cambridge, UK
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Putzer G, Martini J, Spraider P, Hornung R, Pinggera D, Abram J, Altaner N, Hell T, Glodny B, Helbok R, Mair P. Effects of different adrenaline doses on cerebral oxygenation and cerebral metabolism during cardiopulmonary resuscitation in pigs. Resuscitation 2020; 156:223-229. [PMID: 32652117 DOI: 10.1016/j.resuscitation.2020.06.024] [Citation(s) in RCA: 25] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/21/2020] [Revised: 05/19/2020] [Accepted: 06/21/2020] [Indexed: 11/17/2022]
Abstract
BACKGROUND The influence of adrenaline during cardiopulmonary resuscitation (CPR) on the neurological outcome of cardiac arrest survivors is unclear. As little is known about the pathophysiological effects of adrenaline on cerebral oxygen delivery and cerebral metabolism we investigated its effects on parameters of cerebral oxygenation and cerebral metabolism in a pig model of CPR. METHODS Fourteen pigs were anesthetized, intubated and instrumented. After 5 min of cardiac arrest CPR was started and continued for 15 min. Animals were randomized to receive bolus injections of either 15 or 30 μg/kg adrenaline every 5 min after commencement of CPR. RESULTS Measurements included mean arterial pressure (MAP), intracranial pressure (ICP), cerebral perfusion pressure (CPP), cerebral regional oxygen saturation (rSO2), brain tissue oxygen tension (PbtO2), arterial and cerebral venous blood gases and cerebral microdialysis parameters, e.g. lactate/pyruvate ratio. Adrenaline induced a significant increase in MAP and CPP in all pigs. However, increases in MAP and CPP were short-lasting and tended to decrease with repetitive bolus administration. There was no statistical difference in any parameter of cerebral oxygenation or metabolism between study groups. CONCLUSIONS Both adrenaline doses resulted in short-lasting CPP peaks which did not translate into improved cerebral tissue oxygen tension and metabolism. Further studies are needed to determine whether other dosing regimens targeting a sustained increase in CPP, may lead to improved brain oxygenation and metabolism, thereby improving neurological outcome of cardiac arrest patients.
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Affiliation(s)
- Gabriel Putzer
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Judith Martini
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria.
| | - Patrick Spraider
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Rouven Hornung
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Daniel Pinggera
- Department of Neurosurgery, Medical University Innsbruck, Austria
| | - Julia Abram
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Niklas Altaner
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
| | - Tobias Hell
- Department of Mathematics, Faculty of Mathematics, Computer Science and Physics, University of Innsbruck, Austria
| | - Bernhard Glodny
- Department of Radiology, Medical University Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University Innsbruck, Austria
| | - Peter Mair
- Department of Anaesthesiology and Critical Care Medicine, Medical University Innsbruck, Austria
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15
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Zeiler FA, Beqiri E, Cabeleira M, Hutchinson PJ, Stocchetti N, Menon DK, Czosnyka M, Smielewski P, Ercole A. Brain Tissue Oxygen and Cerebrovascular Reactivity in Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Exploratory Analysis of Insult Burden. J Neurotrauma 2020; 37:1854-1863. [PMID: 32253987 DOI: 10.1089/neu.2020.7024] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pressure reactivity index (PRx) and brain tissue oxygen (PbtO2) are associated with outcome in traumatic brain injury (TBI). This study explores the relationship between PRx and PbtO2 in adult moderate/severe TBI. Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high resolution intensive care unit (ICU) sub-study cohort, we evaluated those patients with archived high-frequency digital intraparenchymal intracranial pressure (ICP) and PbtO2 monitoring data of, a minimum of 6 h in duration, and the presence of a 6 month Glasgow Outcome Scale -Extended (GOSE) score. Digital physiological signals were processed for ICP, PbtO2, and PRx, with the % time above/below defined thresholds determined. The duration of ICP, PbtO2, and PRx derangements was characterized. Associations with dichotomized 6-month GOSE (alive/dead, and favorable/unfavorable outcome; ≤ 4 = unfavorable), were assessed. A total of 43 patients were included. Severely impaired cerebrovascular reactivity was seen during elevated ICP and low PbtO2 episodes. However, most of the acute ICU physiological derangements were impaired cerebrovascular reactivity, not ICP elevations or low PbtO2 episodes. Low PbtO2 without PRx impairment was rarely seen. % time spent above PRx threshold was associated with mortality at 6 months for thresholds of 0 (area under the curve [AUC] 0.734, p = 0.003), > +0.25 (AUC 0.747, p = 0.002) and > +0.35 (AUC 0.745, p = 0.002). Similar relationships were not seen for % time with ICP >20 mm Hg, and PbtO2 < 20 mm Hg in this cohort. Extreme impairment in cerebrovascular reactivity is seen during concurrent episodes of elevated ICP and low PbtO2. However, the majority of the deranged cerebral physiology seen during the acute ICU phase is impairment in cerebrovascular reactivity, with most impairment occurring in the presence of normal PbtO2 levels. Measures of cerebrovascular reactivity appear to display the most consistent associations with global outcome in TBI, compared with ICP and PbtO2.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - David K Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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