Imaging and decision-making in neurocritical care

Prognostic Neuroimaging Biomarkers in Acute Vascular Brain Injury and Traumatic Brain Injury

Prognostic imaging biomarkers after acute brain injury inform treatment decisions, track the progression of intracranial injury, and can be used in shared decision-making processes with families. Herein, key established biomarkers and prognostic scoring systems are surveyed in the literature, and their applications in clinical practice and clinical trials are discussed. Biomarkers in acute ischemic stroke include computed tomography (CT) hypodensity scoring, diffusion-weighted lesion volume, and core infarct size on perfusion imaging. Intracerebral hemorrhage biomarkers include hemorrhage volume, expansion, and location. Aneurysmal subarachnoid biomarkers include hemorrhage grading, presence of diffusion-restricting lesions, and acute hydrocephalus. Traumatic brain injury CT scoring systems, contusion expansion, and diffuse axonal injury grading are reviewed. Emerging biomarkers including white matter disease scoring, diffusion tensor imaging, and the automated calculation of scoring systems and volumetrics are discussed.

Description and Contribution of Brain Magnetic Resonance Imaging in Nontraumatic Critically Ill Children

BACKGROUND

The authors aimed to collect all brain magnetic resonance imaging (MRI) performed in critically ill children in the authors' medical pediatric intensive care unit over a 2-year period (2012-2013) to (1) describe the findings and (2) assess its contribution on practical patient care.

METHODS

This is a single-center and retrospective study. All children without traumatic brain injury who underwent a brain MRI during pediatric intensive care unit stays were included. To assess the exam's contribution, the patient's medical condition at the time of the MRI exam was blindly and separately exposed to a pediatric neurologist and a pediatric intensivist.

RESULTS

During the study period, 87 patients (7.5%) underwent a brain MRI. Median age was 4 months and 13 children (14.9%) died in pediatric intensive care unit. The most common final diagnosis was postanoxic encephalopathy. Brain MRI was abnormal in 68 patients (78.2%). No serious adverse event occurred during the transport. The neurologist and the intensivist considered brain MRI as indicated during pediatric intensive care unit stay in 65 (74.7%) and 68 patients (78.2%). They deemed that brain MRI had a diagnostic contribution in 76 (87.4%) and 60 (69.0%) patients, respectively. A therapeutic change consecutive to MRI findings occurred in 19 patients (21.8%) and MRI results were associated with a decision to withdraw life-sustaining treatment in 21 patients (24.1%).

CONCLUSION

Brain MRI is one component of neuromonitoring, and this study suggests a substantial diagnostic contribution, although its therapeutic impact appears limited to specific diagnoses.

Advances in cerebral monitoring for the patient with traumatic brain injury

A brief overview of the most common invasive and noninvasive monitoring tools collectively referred to using the term "multimodal monitoring" is provided. Caring for the critically ill patient with traumatic brain injury requires careful monitoring to prevent or reduce secondary brain injury. Concurrent to the growth of the subspecialty of neurocritical care, there has been a concerted effort to discover novel mechanisms to monitor the physiology of brain injury. The past 2 decades have witnessed an exponential growth in neurologic monitoring in terms of intracranial pressure, blood flow, metabolism, oxygenation, advanced neuroimaging, and electrophysiology.