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Fedriga M, Martini S, Iodice FG, Sortica da Costa C, Pezzato S, Moscatelli A, Beqiri E, Czosnyka M, Smielewski P, Agrawal S. Cerebral autoregulation in paediatric and neonatal intensive care: A scoping review. J Cereb Blood Flow Metab 2024:271678X241261944. [PMID: 38867574 DOI: 10.1177/0271678x241261944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Deranged cerebral autoregulation (CA) is associated with worse outcome in adult brain injury. Strategies for monitoring CA and maintaining the brain at its 'best CA status' have been implemented, however, this approach has not yet developed for the paediatric population. This scoping review aims to find up-to-date evidence on CA assessment in children and neonates with a view to identify patient categories in which CA has been measured so far, CA monitoring methods and its relationship with clinical outcome if any. A literature search was conducted for studies published within 31st December 2022 in 3 bibliographic databases. Out of 494 papers screened, this review includes 135 studies. Our literature search reveals evidence for CA measurement in the paediatric population across different diagnostic categories and age groups. The techniques adopted, indices and thresholds used to assess and define CA are heterogeneous. We discuss the relevance of available evidence for CA assessment in the paediatric population. However, due to small number of studies and heterogeneity of methods used, there is no conclusive evidence to support universal adoption of CA monitoring, technique, and methodology. This calls for further work to understand the clinical impact of CA monitoring in paediatric and neonatal intensive care.
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Affiliation(s)
- Marta Fedriga
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca G Iodice
- Paediatric Cardiac Anaesthesia and Intensive Care Unit, IRCCS, Bambino Gesu' Hospital, Rome, Italy
| | | | - Stefano Pezzato
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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Martini S, Thewissen L, Austin T, da Costa CS, de Boode WP, Dempsey E, Kooi E, Pellicer A, Rhee CJ, Riera J, Wolf M, Wong F. Near-infrared spectroscopy monitoring of neonatal cerebrovascular reactivity: where are we now? Pediatr Res 2023:10.1038/s41390-023-02574-6. [PMID: 36997690 DOI: 10.1038/s41390-023-02574-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/27/2022] [Revised: 02/09/2023] [Accepted: 02/17/2023] [Indexed: 06/19/2023]
Abstract
Cerebrovascular reactivity defines the ability of the cerebral vasculature to regulate its resistance in response to both local and systemic factors to ensure an adequate cerebral blood flow to meet the metabolic demands of the brain. The increasing adoption of near-infrared spectroscopy (NIRS) for non-invasive monitoring of cerebral oxygenation and perfusion allowed investigation of the mechanisms underlying cerebrovascular reactivity in the neonatal population, confirming important associations with pathological conditions including the development of brain injury and adverse neurodevelopmental outcomes. However, the current literature on neonatal cerebrovascular reactivity is mainly still based on small, observational studies and is characterised by methodological heterogeneity; this has hindered the routine application of NIRS-based monitoring of cerebrovascular reactivity to identify infants most at risk of brain injury. This review aims (1) to provide an updated review on neonatal cerebrovascular reactivity, assessed using NIRS; (2) to identify critical points that need to be addressed with targeted research; and (3) to propose feasibility trials in order to fill the current knowledge gaps and to possibly develop a preventive or curative approach for preterm brain injury. IMPACT: NIRS monitoring has been largely applied in neonatal research to assess cerebrovascular reactivity in response to blood pressure, PaCO2 and other biochemical or metabolic factors, providing novel insights into the pathophysiological mechanisms underlying cerebral blood flow regulation. Despite these insights, the current literature shows important pitfalls that would benefit to be addressed in a series of targeted trials, proposed in the present review, in order to translate the assessment of cerebrovascular reactivity into routine monitoring in neonatal clinical practice.
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Affiliation(s)
- Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOU S. Orsola, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy.
| | | | - Topun Austin
- Neonatal Intensive Care Unit, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | | | - Willem P de Boode
- Department of Neonatology, Radboud University Medical Center, Radboud Institute for Health Sciences, Amalia Children's Hospital, Nijmegen, The Netherlands
| | - Eugene Dempsey
- Department of Paediatrics and Child Health, INFANT Centre, University College Cork, Cork, Ireland
| | - Elisabeth Kooi
- Division of Neonatology, Beatrix Children's Hospital, University Medical Center, University of Groningen, Groningen, The Netherlands
| | - Adelina Pellicer
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
| | - Christopher J Rhee
- Section of Neonatology, Baylor College of Medicine, Texas Children's Hospital, Houston, TX, USA
| | - Joan Riera
- Department of Neonatology, La Paz University Hospital, Madrid, Spain
- Center for Biomedical Technology, Technical University, Madrid, Spain
| | - Martin Wolf
- Biomedical Optics Research Laboratory, Department of Neonatology, University Hospital Zurich, Zurich, Switzerland
| | - Flora Wong
- Monash Newborn, Monash Children's Hospital, Hudson Institute of Medical Research, Department of Paediatrics, Monash University, Melbourne, VIC, Australia
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Liu X, Tekes A, Perin J, Chen MW, Soares BP, Massaro AN, Govindan RB, Parkinson C, Chavez-Valdez R, Northington FJ, Brady KM, Lee JK. Wavelet Autoregulation Monitoring Identifies Blood Pressures Associated With Brain Injury in Neonatal Hypoxic-Ischemic Encephalopathy. Front Neurol 2021; 12:662839. [PMID: 33995258 PMCID: PMC8113412 DOI: 10.3389/fneur.2021.662839] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 03/22/2021] [Indexed: 11/15/2022] Open
Abstract
Dysfunctional cerebrovascular autoregulation may contribute to neurologic injury in neonatal hypoxic-ischemic encephalopathy (HIE). Identifying the optimal mean arterial blood pressure (MAPopt) that best supports autoregulation could help identify hemodynamic goals that support neurologic recovery. In neonates who received therapeutic hypothermia for HIE, we hypothesized that the wavelet hemoglobin volume index (wHVx) would identify MAPopt and that blood pressures closer to MAPopt would be associated with less brain injury on MRI. We also tested a correlation-derived hemoglobin volume index (HVx) and single- and multi-window data processing methodology. Autoregulation was monitored in consecutive 3-h periods using near infrared spectroscopy in an observational study. The neonates had a mean MAP of 54 mmHg (standard deviation: 9) during hypothermia. Greater blood pressure above the MAPopt from single-window wHVx was associated with less injury in the paracentral gyri (p = 0.044; n = 63), basal ganglia (p = 0.015), thalamus (p = 0.013), and brainstem (p = 0.041) after adjustments for sex, vasopressor use, seizures, arterial carbon dioxide level, and a perinatal insult score. Blood pressure exceeding MAPopt from the multi-window, correlation HVx was associated with less injury in the brainstem (p = 0.021) but not in other brain regions. We conclude that applying wavelet methodology to short autoregulation monitoring periods may improve the identification of MAPopt values that are associated with brain injury. Having blood pressure above MAPopt with an upper MAP of ~50–60 mmHg may reduce the risk of brain injury during therapeutic hypothermia. Though a cause-and-effect relationship cannot be inferred, the data support the need for randomized studies of autoregulation and brain injury in neonates with HIE.
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Affiliation(s)
- Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Aylin Tekes
- Department of Radiology, Johns Hopkins University, Baltimore, MD, United States
| | - Jamie Perin
- Department of Pediatrics, Center for Child and Community Health Research, Johns Hopkins University, Baltimore, MD, United States
| | - May W Chen
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | - Bruno P Soares
- Department of Radiology, University of Vermont, Burlington, VT, United States
| | - An N Massaro
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States.,Division of Neonatology, Children's National Health System, Washington, DC, United States
| | - Rathinaswamy B Govindan
- Fetal Medicine Institute, Children's National Health System, Washington, DC, United States.,The George Washington University School of Medicine, Washington, DC, United States
| | | | - Raul Chavez-Valdez
- Division of Neonatology, Johns Hopkins University, Baltimore, MD, United States
| | | | - Ken M Brady
- Department of Anesthesiology, Lurie Children's Hospital, Chicago, IL, United States
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, United States
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4
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Later cooling within 6 h and temperatures outside 33-34 °C are not associated with dysfunctional autoregulation during hypothermia for neonatal encephalopathy. Pediatr Res 2021; 89:223-230. [PMID: 32268341 PMCID: PMC7541414 DOI: 10.1038/s41390-020-0876-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/15/2019] [Revised: 01/10/2020] [Accepted: 03/07/2020] [Indexed: 01/19/2023]
Abstract
BACKGROUND Cooling delays, temperature outside 33-34 °C, and blood pressure below the mean arterial blood pressure with optimal cerebral autoregulation (MAPOPT) might diminish neuroprotection from therapeutic hypothermia in neonates with hypoxic-ischemic encephalopathy (HIE). We hypothesized that longer time to reach temperature <34 °C and having temperature outside 33-34 °C would be associated with worse autoregulation and greater brain injury. METHODS Neonates with HIE had rectal temperature and near-infrared spectroscopy autoregulation monitoring during hypothermia (n = 63) and rewarming (n = 58). All underwent brain MRI, and a subset received diffusion tensor imaging MRI before day 10 (n = 41). RESULTS Most neonates reached <34 °C at 3-6 h of life. MAPOPT was identified in 54/63 (86%) during hypothermia and in 53/58 (91%) during rewarming. Cooling time was not related to blood pressure deviation from MAPOPT. Later cooling was associated with lower ADC scalar in unilateral posterior centrum semiovale but not in other regions. Temperatures >34 °C were associated with blood pressure above MAPOPT but not with brain injury. CONCLUSIONS In neonates who were predominantly cooled after 3 h, cooling time was not associated with autoregulation or overall brain injury. Blood pressure deviation above MAPOPT was associated with temperature >34 °C. Additional studies are needed in a more heterogeneous population. IMPACT Cooling time to reach target hypothermia temperature within 6 h of birth did not affect cerebral autoregulation measured by NIRS in neonates with hypoxic-ischemic encephalopathy (HIE). Temperature fluctuations >33-34 °C were associated with blood pressures that exceeded the range of optimal autoregulatory vasoreactivity. Cooling time within 6 h of birth and temperatures >33-34 °C were not associated with qualitative brain injury on MRI. Regional apparent diffusion coefficient scalars on diffusion tensor imaging MRI were not appreciably affected by cooling time or temperature >33-34 °C. Additional research in a larger and more heterogeneous population is needed to determine how delayed cooling and temperatures beyond the target hypothermia range affect autoregulation and brain injury.
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Massaro AN, Lee JK, Vezina G, Glass P, O'Kane A, Li R, Chang T, Brady K, Govindan R. Exploratory Assessment of the Relationship Between Hemoglobin Volume Phase Index, Magnetic Resonance Imaging, and Functional Outcome in Neonates with Hypoxic-Ischemic Encephalopathy. Neurocrit Care 2020; 35:121-129. [PMID: 33215394 DOI: 10.1007/s12028-020-01150-8] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/19/2020] [Accepted: 11/03/2020] [Indexed: 10/23/2022]
Abstract
BACKGROUND/OBJECTIVE Near-infrared spectroscopy (NIRS)-based measures of cerebral autoregulation (CAR) can potentially identify neonates with hypoxic-ischemic encephalopathy (HIE) who are at greatest risk of irreversible brain injury. However, modest predictive abilities have precluded previously described metrics from entering clinical care. We previously validated a novel autoregulation metric in a piglet model of induced hypotension called the hemoglobin volume phase index (HVP). The objective of this study was to evaluate the clinical ability of the HVP to predict adverse outcomes neonates with HIE. METHODS This is a prospective study of neonates with HIE who underwent therapeutic hypothermia (TH) at a level 4 neonatal intensive care unit (NICU). Continuous cerebral NIRS and mean arterial blood pressure (MAP) from indwelling arterial catheters were measured during TH and through rewarming. Multivariate autoregressive process was used to calculate the coherence between MAP and the sum total of the oxy- and deoxygenated Hb densities (HbT), a surrogate measure of cerebral blood volume (CBV). The HVP was calculated as the cosine-transformed phase shift at the frequency of maximal MAP-HbT coherence. Brain injury was assessed by neonatal magnetic resonance imaging (MRI), and developmental outcomes were assessed by the Bayley Scales of Infant Development (BSID-III) at 15-30 months. The ability of the HVP to predict (a) death or severe brain injury by MRI and (b) death or significant developmental delay was assessed using logistic regression analyses. RESULTS In total, 50 neonates with moderate or severe HIE were monitored. Median HVP was higher, representing more dysfunctional autoregulation, in infants who had adverse outcomes. After adjusting for sex and encephalopathy grade at presentation, HVP at 21-24 and 24-27 h of life predicted death or brain injury by MRI (21-24 h: OR 8.8, p = 0.037; 24-27 h: OR 31, p = 0.011) and death or developmental delay at 15-30 months (21-24 h: OR 11.8, p = 0.05; 24-27 h: OR 15, p = 0.035). CONCLUSIONS Based on this pilot study of neonates with HIE, HVP merits further study as an indicator of death or severe brain injury on neonatal MRI and neurodevelopmental delay in early childhood. Larger studies are warranted for further clinical validation of the HVP to evaluate cerebral autoregulation following HIE.
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Affiliation(s)
- An N Massaro
- Division of Neonatology, Children's National Hospital, Washington, DC, USA. .,The George Washington University School of Medicine, Washington, DC, USA.
| | - Jennifer K Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Gilbert Vezina
- Diagnostic Imaging and Radiology, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | - Penny Glass
- Psychology and Behavioral Health, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | | | - Ruoying Li
- Neurology, Children's National Hospital, Washington, DC, USA
| | - Taeun Chang
- Neurology, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
| | - Kenneth Brady
- Department of Anesthesia, Ann and Robert H. Lurie Children's Hospital of Chicago, Chicago, IL, USA
| | - Rathinaswamy Govindan
- Fetal and Transitional Medicine, Children's National Hospital, Washington, DC, USA.,The George Washington University School of Medicine, Washington, DC, USA
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6
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Head Ultrasound Resistive Indices Are Associated With Brain Injury on Diffusion Tensor Imaging Magnetic Resonance Imaging in Neonates With Hypoxic-Ischemic Encephalopathy. J Comput Assist Tomogr 2020; 44:687-691. [PMID: 32842070 DOI: 10.1097/rct.0000000000001069] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
BACKGROUND Neonatal hypoxic-ischemic encephalopathy (HIE) is associated with dysfunctional cerebral autoregulation. Resistive index (RI) measured in the anterior cerebral artery on transfontanellar head ultrasound is a noninvasive measure of blood flow and may indicate autoregulation dysfunction. We tested whether RI was associated with brain injury on diffusion tensor imaging magnetic resonance imaging (MRI). MATERIALS AND METHODS Seventy-five neonates who underwent therapeutic hypothermia for HIE were enrolled. Resistive index values were obtained from head ultrasound performed at the end of therapeutic hypothermia. Apparent diffusion coefficient scalars were measured on MRIs performed before day of life 10. RESULTS Lower RI was associated with lower apparent diffusion coefficient in the centrum semiovale, basal ganglia, thalamus, and posterior limb of the internal capsule. Combining RI and Apgar scores improved the ability to distinguish injury severity on MRI relative to either metric alone. CONCLUSIONS Low RI correlated with worse brain injury on diffusion tensor imaging and may serve as an early marker of brain injury in cooled HIE neonates.
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7
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Carrasco M, Stafstrom CE, Tekes A, Parkinson C, Northington FJ. The Johns Hopkins Neurosciences Intensive Care Nursery Tenth Anniversary (2009-2019): A Historical Reflection and Vision for the Future. Child Neurol Open 2020; 7:2329048X20907761. [PMID: 32215280 PMCID: PMC7081468 DOI: 10.1177/2329048x20907761] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/22/2019] [Revised: 12/16/2019] [Accepted: 01/16/2020] [Indexed: 12/11/2022] Open
Abstract
Since 2009, the Neurosciences Intensive Care Nursery at Johns Hopkins Children’s Center has provided a multidisciplinary approach toward the care of newborns with neurological disorders. The program’s cornerstone is an interdisciplinary approach that involves the primary neonatology team plus experts from more than 10 specialties who convene at a weekly team conference at which newborns with neurological problems are discussed in detail. This interdisciplinary approach fosters in-depth discussion of clinical issues to optimize the management of neonates with neurological problems as well as the opportunity to generate research ideas and provide education about neonatal neuroscience at all levels (faculty, nurses, and trainees). The purpose of this article is to provide a 10-year reflection of our Neurosciences Intensive Care Nursery with a view toward expanding efforts in the 3 areas of our mission: clinical care, research, and education. We hope that our experience will enhance the spread of neonatal neuroscience education, care, and research as widely as possible.
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Affiliation(s)
- Melisa Carrasco
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Carl E Stafstrom
- Division of Pediatric Neurology, Department of Neurology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Aylin Tekes
- Division of Pediatric Radiology and Pediatric Neuroradiology, Department of Radiology, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Charla Parkinson
- Division of Neonatology, Department of Pediatrics, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
| | - Frances J Northington
- Division of Neonatology, Department of Pediatrics, School of Medicine, The Johns Hopkins University, Baltimore, MD, USA
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McNally MA, Chavez-Valdez R, Felling RJ, Flock DL, Northington FJ, Stafstrom CE. Seizure Susceptibility Correlates with Brain Injury in Male Mice Treated with Hypothermia after Neonatal Hypoxia-Ischemia. Dev Neurosci 2019; 40:1-10. [PMID: 30820019 PMCID: PMC9109068 DOI: 10.1159/000496468] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/01/2018] [Accepted: 12/20/2018] [Indexed: 11/19/2022] Open
Abstract
Hypoxic-ischemic encephalopathy is a common neonatal brain injury associated with significant morbidity and mortality despite the administration of therapeutic hypothermia (TH). Neonatal seizures and subsequent chronic epilepsy are frequent in this patient population and current treatments are partially effective. We used a neonatal murine hypoxia-ischemia (HI) model to test whether the severity of hippocampal and cortical injury predicts seizure susceptibility 8 days after HI and whether TH mitigates this susceptibility. HI at postnatal day 10 (P10) caused hippocampal injury not mitigated by TH in male or female pups. TH did not confer protection against flurothyl seizure susceptibility at P18 in this model. Hippocampal (R2 = 0.33, p = 0.001) and cortical (R2 = 0.33, p = 0.003) injury directly correlated with seizure susceptibility in male but not female pups. Thus, there are sex-specific consequences of neonatal HI on flurothyl seizure susceptibility in a murine neonatal HI model. Further studies are necessary to elucidate the underlying mechanisms of sex dimorphism in seizure susceptibility after neonatal HI.
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Affiliation(s)
- Melanie A McNally
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA,
- Department of Neurology, Boston Children's Hospital, Harvard Medical School, Boston, Massachusetts, USA,
| | - Raul Chavez-Valdez
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Ryan J Felling
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Debra L Flock
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Frances J Northington
- Department of Pediatrics (Neonatology), Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
| | - Carl E Stafstrom
- Department of Neurology, Johns Hopkins University School of Medicine, Baltimore, Maryland, USA
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9
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Rhee CJ, da Costa CS, Austin T, Brady KM, Czosnyka M, Lee JK. Neonatal cerebrovascular autoregulation. Pediatr Res 2018; 84:602-610. [PMID: 30196311 PMCID: PMC6422675 DOI: 10.1038/s41390-018-0141-6] [Citation(s) in RCA: 95] [Impact Index Per Article: 15.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/26/2018] [Revised: 06/04/2018] [Accepted: 07/27/2018] [Indexed: 12/12/2022]
Abstract
Cerebrovascular pressure autoregulation is the physiologic mechanism that holds cerebral blood flow (CBF) relatively constant across changes in cerebral perfusion pressure (CPP). Cerebral vasoreactivity refers to the vasoconstriction and vasodilation that occur during fluctuations in arterial blood pressure (ABP) to maintain autoregulation. These are vital protective mechanisms of the brain. Impairments in pressure autoregulation increase the risk of brain injury and persistent neurologic disability. Autoregulation may be impaired during various neonatal disease states including prematurity, hypoxic-ischemic encephalopathy (HIE), intraventricular hemorrhage, congenital cardiac disease, and infants requiring extracorporeal membrane oxygenation (ECMO). Because infants are exquisitely sensitive to changes in cerebral blood flow (CBF), both hypoperfusion and hyperperfusion can cause significant neurologic injury. We will review neonatal pressure autoregulation and autoregulation monitoring techniques with a focus on brain protection. Current clinical therapies have failed to fully prevent permanent brain injuries in neonates. Adjuvant treatments that support and optimize autoregulation may improve neurologic outcomes.
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Affiliation(s)
- Christopher J. Rhee
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Section of Neonatology, Houston, TX, USA
| | | | - Topun Austin
- Neonatal Unit, Rosie Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ken M. Brady
- Baylor College of Medicine, Texas Children’s Hospital, Department of Pediatrics, Critical Care Medicine and Anesthesiology, Houston, TX, USA
| | - Marek Czosnyka
- Department of Academic Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
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10
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Lee JK, Williams M, Reyes M, Ahn ES. Cerebrovascular blood pressure autoregulation monitoring and postoperative transient ischemic attack in pediatric moyamoya vasculopathy. Paediatr Anaesth 2018; 28:94-102. [PMID: 29205668 PMCID: PMC5960234 DOI: 10.1111/pan.13293] [Citation(s) in RCA: 20] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Accepted: 10/31/2017] [Indexed: 01/01/2023]
Abstract
BACKGROUND Children with moyamoya vasculopathy are at high risk of perioperative cerebral ischemia or hyperperfusion. Maintaining blood pressure within the range of functional cerebrovascular blood pressure autoregulation might reduce the risk of perioperative neurologic injury. AIMS We tested whether blood pressure autoregulation is associated with postoperative transient ischemic attack in a study of patients with pediatric moyamoya vasculopathy. METHODS We conducted an observational study of 15 pediatric patients undergoing surgical revascularization with pial synangiosis. Nine patients had bilateral moyamoya and 6 had unilateral moyamoya. We measured autoregulatory vasoreactivity intraoperatively and during the first postoperative night with the hemoglobin volume index, a value derived from near-infrared spectroscopy. We also identified the optimal mean arterial blood pressure at which autoregulation was most robust in each patient. RESULTS Of the 15 children monitored, 3 with bilateral moyamoya and one with unilateral moyamoya experienced a transient ischemic attack. Poorer autoregulation during surgery was associated with postoperative transient ischemic attack among those with bilateral vasculopathy (P = .048, difference in hemoglobin volume index medians: 0.023, 95% confidence interval: 0.003-0.071). This relationship was not observed with postoperative autoregulation. The optimal mean arterial blood pressure was identifiable during surgery in all monitored patients, varied among patients, and often differed between the intraoperative and postoperative periods. CONCLUSION Dysfunctional intraoperative autoregulation may increase the risk of TIA in patients with pediatric moyamoya vasculopathy. The blood pressure range that supports autoregulation appears to vary among patients. Using autoregulation monitoring to guide individualized blood pressure goals should be studied as a potential method to reduce perioperative neurologic morbidity in pediatric patients with moyamoya.
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Affiliation(s)
- Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Monica Williams
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Michael Reyes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins University, Baltimore, MD, USA
| | - Edward S. Ahn
- Department of Neurosurgery, Johns Hopkins University, Baltimore, MD, USA
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11
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Thewissen L, Caicedo A, Lemmers P, Van Bel F, Van Huffel S, Naulaers G. Measuring Near-Infrared Spectroscopy Derived Cerebral Autoregulation in Neonates: From Research Tool Toward Bedside Multimodal Monitoring. Front Pediatr 2018; 6:117. [PMID: 29868521 PMCID: PMC5960703 DOI: 10.3389/fped.2018.00117] [Citation(s) in RCA: 24] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/14/2017] [Accepted: 04/11/2018] [Indexed: 12/30/2022] Open
Abstract
Introduction: Cerebral autoregulation (CAR), the ability of the human body to maintain cerebral blood flow (CBF) in a wide range of perfusion pressures, can be calculated by describing the relation between arterial blood pressure (ABP) and cerebral oxygen saturation measured by near-infrared spectroscopy (NIRS). In literature, disturbed CAR is described in different patient groups, using multiple measurement techniques and mathematical models. Furthermore, it is unclear to what extent cerebral pathology and outcome can be explained by impaired CAR. Aim and methods: In order to summarize CAR studies using NIRS in neonates, a systematic review was performed in the PUBMED and EMBASE database. To provide a general overview of the clinical framework used to study CAR, the different preprocessing methods and mathematical models are described and explained. Furthermore, patient characteristics, definition of impaired CAR and the outcome according to this definition is described organized for the different patient groups. Results: Forty-six articles were included in this review. Four patient groups were established: preterm infants during the transitional period, neonates receiving specific medication/treatment, neonates with congenital heart disease and neonates with hypoxic-ischemic encephalopathy (HIE) treated with therapeutic hypothermia. Correlation, coherence and transfer function (TF) gain are the mathematical models most frequently used to describe CAR. The definition of impaired CAR is depending on the mathematical model used. The incidence of intraventricular hemorrhage in preterm infants is the outcome variable most frequently correlated with impaired CAR. Hypotension, disease severity, dopamine treatment, injury on magnetic resonance imaging (MRI) and long term outcome are associated with impaired CAR. Prospective interventional studies are lacking in all research areas. Discussion and conclusion: NIRS derived CAR measurement is an important research tool to improve knowledge about central hemodynamic fluctuations during the transitional period, cerebral pharmacodynamics of frequently used medication (sedatives-inotropes) and cerebral effects of specific therapies in neonatology. Uniformity regarding measurement techniques and mathematical models is needed. Multimodal monitoring databases of neonatal intensive care patients of multiple centers, together with identical outcome parameters are needed to compare different techniques and make progress in this field. Real-time bedside monitoring of CAR, together with conventional monitoring, seems a promising technique to improve individual patient care.
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Affiliation(s)
- Liesbeth Thewissen
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
| | - Alexander Caicedo
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Petra Lemmers
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Frank Van Bel
- Department of Neonatology, University Medical Center Utrecht, Utrecht, Netherlands
| | - Sabine Van Huffel
- Department of Electrical Engineering, ESAT-Stadius, KU Leuven, Leuven, Belgium.,Interuniversity Microelectronics Centre, Leuven, Belgium
| | - Gunnar Naulaers
- Department of Neonatology, University Hospitals Leuven, Leuven, Belgium.,Department of Development and Regeneration, KU Leuven, Leuven, Belgium
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Dietrich WD, Bramlett HM. Therapeutic hypothermia and targeted temperature management for traumatic brain injury: Experimental and clinical experience. Brain Circ 2017; 3:186-198. [PMID: 30276324 PMCID: PMC6057704 DOI: 10.4103/bc.bc_28_17] [Citation(s) in RCA: 31] [Impact Index Per Article: 4.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2017] [Revised: 11/20/2017] [Accepted: 11/24/2017] [Indexed: 12/21/2022] Open
Abstract
Traumatic brain injury (TBI) is a worldwide medical problem, and currently, there are few therapeutic interventions that can protect the brain and improve functional outcomes in patients. Over the last several decades, experimental studies have investigated the pathophysiology of TBI and tested various pharmacological treatment interventions targeting specific mechanisms of secondary damage. Although many preclinical treatment studies have been encouraging, there remains a lack of successful translation to the clinic and no therapeutic treatments have shown benefit in phase 3 multicenter trials. Therapeutic hypothermia and targeted temperature management protocols over the last several decades have demonstrated successful reduction of secondary injury mechanisms and, in some selective cases, improved outcomes in specific TBI patient populations. However, the benefits of therapeutic hypothermia have not been demonstrated in multicenter randomized trials to significantly improve neurological outcomes. Although the exact reasons underlying the inability to translate therapeutic hypothermia into a larger clinical population are unknown, this failure may reflect the suboptimal use of this potentially powerful therapeutic in potentially treatable severe trauma patients. It is known that multiple factors including patient recruitment, clinical treatment variables, and cooling methodologies are all important in yielding beneficial effects. High-quality multicenter randomized controlled trials that incorporate these factors are required to maximize the benefits of this experimental therapy. This article therefore summarizes several factors that are important in enhancing the beneficial effects of therapeutic hypothermia in TBI. The current failures of hypothermic TBI clinical trials in terms of clinical protocol design, patient section, and other considerations are discussed and future directions are emphasized.
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Affiliation(s)
- W Dalton Dietrich
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
| | - Helen M Bramlett
- Department of Neurological Surgery, The Miami Project to Cure Paralysis, University of Miami Miller School of Medicine, Miami, FL, USA
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Lee JK, Perin J, Parkinson C, O’Connor M, Gilmore MM, Reyes M, Armstrong J, Jennings J, Northington FJ, Chavez-Valdez R. Relationships between cerebral autoregulation and markers of kidney and liver injury in neonatal encephalopathy and therapeutic hypothermia. J Perinatol 2017; 37:938-942. [PMID: 28471439 PMCID: PMC5578902 DOI: 10.1038/jp.2017.64] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/23/2017] [Revised: 03/30/2017] [Accepted: 04/03/2017] [Indexed: 12/18/2022]
Abstract
OBJECTIVE We studied whether cerebral blood pressure autoregulation and kidney and liver injuries are associated in neonatal encephalopathy (NE). STUDY DESIGN We monitored autoregulation of 75 newborns who received hypothermia for NE in the neonatal intensive care unit to identify the mean arterial blood pressure with optimized autoregulation (MAPOPT). Autoregulation parameters and creatinine, aspartate aminotransferase (AST) and alanine aminotransferase (ALT) were analyzed using adjusted regression models. RESULTS Greater time with blood pressure within MAPOPT during hypothermia was associated with lower creatinine in girls. Blood pressure below MAPOPT related to higher ALT and AST during normothermia in all neonates and boys. The opposite occurred in rewarming when more time with blood pressure above MAPOPT related to higher AST. CONCLUSIONS Blood pressures that optimize cerebral autoregulation may support the kidneys. Blood pressures below MAPOPT and liver injury during normothermia are associated. The relationship between MAPOPT and AST during rewarming requires further study.
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Affiliation(s)
- Jennifer K. Lee
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD,Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jamie Perin
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Charlamaine Parkinson
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Matthew O’Connor
- Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Maureen M. Gilmore
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Michael Reyes
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jillian Armstrong
- Department of Anesthesiology and Critical Care Medicine, Johns Hopkins School of Medicine, Baltimore, MD
| | - Jacky Jennings
- Center for Child and Community Health Research (CCHR), Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Frances J. Northington
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
| | - Raul Chavez-Valdez
- Neurosciences Intensive Care Nursery, Johns Hopkins School of Medicine, Baltimore, MD,Division of Neonatology, Department of Pediatrics, Johns Hopkins School of Medicine, Baltimore, MD
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