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Jaishankar R, Teichmann D, Hayward A, Holsapple JW, Heldt T. Open cranium model for the study of cerebrovascular dynamics in intracranial hypertension. J Neurosci Methods 2024; 409:110196. [PMID: 38880344 DOI: 10.1016/j.jneumeth.2024.110196] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Revised: 03/16/2024] [Accepted: 06/10/2024] [Indexed: 06/18/2024]
Abstract
BACKGROUND Significant research has been devoted to developing noninvasive approaches to neuromonitoring. Clinical validation of such approaches is often limited, with minimal data available in the clinically relevant elevated ICP range. NEW METHOD To allow ultrasound-guided placement of an intraventricular catheter and to perform simultaneous long-duration ICP and ultrasound recordings of cerebral blood flow, we developed a large unilateral craniectomy in a swine model. We also used a microprocessor-controlled actuator for intraventricular saline infusion to reliably and reversibly manipulate ICP according to pre-determined profiles. RESULTS The model was reproducible, resulting in over 80 hours of high-fidelity, multi-parameter physiological waveform recordings in twelve animals, with ICP ranging from 2 to 78 mmHg. ICP elevations were reversible and reproducible according to two predetermined profiles: a stepwise elevation up to an ICP of 30-35 mmHg and return to normotension, and a clinically significant plateau wave. Finally, ICP was elevated to extreme levels of greater than 60 mmHg, simulating extreme clinical emergency. COMPARISON WITH EXISTING METHODS Existing methods for ICP monitoring in large animals typically relied on burr-hole approaches for catheter placement. Accurate catheter placement can be difficult in pigs, given the thickness of their skull. Additionally, ultrasound is significantly attenuated by the skull. The open cranium model overcomes these limitations. CONCLUSIONS The hemicraniectomy model allowed for verified placement of the intraventricular catheter, and reversible and reliable ICP manipulation over a wide range. The large dural window additionally allowed for long-duration recording of cerebral blood flow velocity from the middle cerebral artery.
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Affiliation(s)
- Rohan Jaishankar
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Daniel Teichmann
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - Alison Hayward
- Division of Comparative Medicine, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Mechanical Engineering, Massachusetts Institute of Technology, Cambridge, MA 02139, USA
| | - James W Holsapple
- Department of Neurosurgery, Boston University School of Medicine, Boston, MA 02118, USA
| | - Thomas Heldt
- Institute for Medical Engineering & Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA; Department of Electrical Engineering & Computer Science, Massachusetts Institute of Technology, Cambridge, MA 02139, USA.
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Klein SP, Decraene B, De Sloovere V, Kempen B, Meyfroidt G, Depreitere B. The Pressure Reactivity Index as a Measure for Cerebrovascular Autoregulation: Validation in a Porcine Cranial Window Model. Neurosurgery 2024:00006123-990000000-01207. [PMID: 38861643 DOI: 10.1227/neu.0000000000003019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/09/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pressure reactivity index (PRx) has been proposed as a metric associated with cerebrovascular autoregulatory (CA) function and has been thoroughly investigated in clinical research. In this study, PRx is validated in a porcine cranial window model, developed to visualize pial arteriolar autoregulation and its limits. METHODS We measured arterial blood pressure, intracranial pressure, pial arteriolar diameter, and red blood cell (RBC) velocity in a closed cranial window piglet model during gradual balloon catheter-induced arterial hypotension (n = 10) or hypertension (n = 10). CA limits were derived through piecewise linear regression of calculated RBC flux vs cerebral perfusion pressure (CPP), leading for each arteriole to 1 lower limit of autoregulation (LLA) and 2 upper limits of autoregulation (ULA1 and ULA2). Autoregulation limits were compared with PRx thresholds, and receiver operating curve analysis was performed with and without CPP binning. A linear mixed effects model of PRx was performed. RESULTS Receiver operating curve analysis indicated an area under the curve (AUC) for LLA prediction by a PRx of 0.65 (95% CI: 0.64-0.67) and 0.77 (95% CI: 0.69-0.86) without and with CPP binning, respectively. The AUC for ULA1 prediction by PRx was 0.69 (95% CI: 0.68-0.69) without and 0.75 (95% CI: 0.68-0.82) with binning. The AUC for ULA2 prediction was 0.55 (95% CI: 0.55-0.58) without and 0.63 (95% CI 0.53-0.72) with binning. The sensitivity and specificity of binned PRx were 65%/90% for LLA, 69%/71% for ULA1, and 59%/74% for ULA2, showing wide interindividual variability. In the linear mixed effects model, pial arteriolar diameter changes were significantly associated with PRx changes (P = .002), whereas RBC velocity (P = .28) and RBC flux (P = .24) were not. CONCLUSION We conclude that PRx is predominantly determined by pial arteriolar diameter changes and moderately predicts CA limits. Performance to detect the CA limits varied highly on an individual level. Active therapeutic strategies based on PRx and the associated correlation metrics should incorporate these limitations.
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Affiliation(s)
- Samuel P Klein
- Neurosurgery Center Limburg, Jessa Hospital, Hasselt, Belgium
| | | | | | - Bavo Kempen
- Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Stathoulopoulos A, Passos A, Kaliviotis E, Balabani S. Partitioning of dense RBC suspensions in single microfluidic bifurcations: role of cell deformability and bifurcation angle. Sci Rep 2024; 14:535. [PMID: 38177195 PMCID: PMC10767057 DOI: 10.1038/s41598-023-49849-w] [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: 09/05/2023] [Accepted: 12/12/2023] [Indexed: 01/06/2024] Open
Abstract
Red blood cells (RBCs) are a key determinant of human physiology and their behaviour becomes extremely heterogeneous as they navigate in narrow, bifurcating vessels in the microvasculature, affecting local haemodynamics. This is due to partitioning in bifurcations which is dependent on the biomechanical properties of RBCs, especially deformability. We examine the effect of deformability on the haematocrit distributions of dense RBC suspensions flowing in a single, asymmetric Y-shaped bifurcation, experimentally. Human RBC suspensions (healthy and artificially hardened) at 20% haematocrit (Ht) were perfused through the microchannels at different flow ratios between the outlet branches, and negligible inertia, and imaged to infer cell distributions. Notable differences in the shape of the haematocrit distributions were observed between healthy and hardened RBCs near the bifurcation apex. These lead to more asymmetric distributions for healthy RBCs in the daughter and outlet branches with cells accumulating near the inner channel walls, exhibiting distinct hematocrit peaks which are sharper for healthy RBCs. Although the hematocrit distributions differed locally, similar partitioning characteristics were observed for both suspensions. Comparisons with RBC distributions measured in a T-shaped bifurcation showed that the bifurcation angle affects the haematocrit characteristics of the healthy RBCs and not the hardened ones. The extent of RBC partitioning was found similar in both geometries and suspensions. The study highlights the differences between local and global characteristics which impact RBC distribution in more complex, multi-bifurcation networks.
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Affiliation(s)
- Antonios Stathoulopoulos
- FluME, Department of Mechanical Engineering, University College London (UCL), London, WC1E 7JE, UK
| | - Andreas Passos
- FluME, Department of Mechanical Engineering, University College London (UCL), London, WC1E 7JE, UK
- Department of Mechanical Engineering and Material Science Engineering, Cyprus University of Technology, Limassol, Cyprus
| | - Efstathios Kaliviotis
- Department of Mechanical Engineering and Material Science Engineering, Cyprus University of Technology, Limassol, Cyprus
| | - Stavroula Balabani
- FluME, Department of Mechanical Engineering, University College London (UCL), London, WC1E 7JE, UK.
- Wellcome/EPSRC Centre for Interventional and Surgical Sciences, University College London (UCL), London, UK.
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Dietvorst S, Vervekken A, Depreitere B. Developing a porcine model of severe traumatic brain injury induced by high amplitude rotational acceleration. BRAIN & SPINE 2023; 4:102728. [PMID: 38510621 PMCID: PMC10951692 DOI: 10.1016/j.bas.2023.102728] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 05/29/2023] [Revised: 11/29/2023] [Accepted: 12/08/2023] [Indexed: 03/22/2024]
Abstract
Introduction It is unclear which pathophysiological processes initiate and drive dynamic cerebrovascular autoregulation (CA) impairment as seen in traumatic brain injury (TBI). This is not solely attributable to raised intracranial pressure (ICP), but also results from local tissue damage. Research question In order to investigate CA disturbing processes, a porcine model is needed that mimics severe TBI as seen in humans. This model requires high amplitude rotational acceleration. Material and methods A customized device was built to produce a rotational impulse with high amplitude and short pulse duration. Following preparatory tests on cadaver piglets, six piglets of six weeks old were sedated, ventilated and subjected to rotational impulses of different magnitudes. The impulse was immediately followed by installment of invasive monitoring of ICP, PbO₂, Laser Doppler Flowmetry and arterial blood pressure. TBI was further characterized by magnetic resonance brain imaging. Results The current setup enabled to reach sagittal head rotational maximal acceleration magnitudes up to 30 krad/s2. Half of the animals had an increase in ICP, measured shortly after the impulse. It has proved impossible so far to produce a sustained rise in ICP as seen in human severe TBI. MRI showed no anatomical abnormalities which would confirm severe TBI. Discussion and conclusion The challenge to build a porcine model in which severe TBI with ICP raise and MRI changes as seen in humans can be reliably reproduced is still ongoing. It might be that higher peak rotational accelerations are needed.
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Affiliation(s)
- Sofie Dietvorst
- Department of Neurosurgery, University Hospitals, Leuven, Belgium
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
| | - Aline Vervekken
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals, Leuven, Belgium
- Research Group Experimental Neurosurgery and Neuroanatomy, KULeuven, Belgium
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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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Bozkurt S, Ayten UE. ln silico simulation of the interaction among autoregulatory mechanisms regulating cerebral blood flow rate in the healthy and systolic heart failure conditions during exercise. Med Biol Eng Comput 2022; 60:1863-1879. [DOI: 10.1007/s11517-022-02585-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Accepted: 04/22/2022] [Indexed: 11/29/2022]
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Klein SP, De Sloovere V, Meyfroidt G, Depreitere B. Differential Hemodynamic Response of Pial Arterioles Contributes to a Quadriphasic Cerebral Autoregulation Physiology. J Am Heart Assoc 2021; 11:e022943. [PMID: 34935426 PMCID: PMC9075199 DOI: 10.1161/jaha.121.022943] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
Abstract
Background Cerebrovascular autoregulation (CA) regulates cerebral vascular tone to maintain near-constant cerebral blood flow during fluctuations in cerebral perfusion pressure (CPP). Preclinical and clinical research has challenged the classic triphasic pressure-flow relationship, leaving the normal pressure-flow relationship unclear. Methods and Results We used in vivo imaging of the hemodynamic response in pial arterioles to study CA in a porcine closed cranial window model during nonpharmacological blood pressure manipulation. Red blood cell flux was determined in 52 pial arterioles during 10 hypotension and 10 hypertension experiments to describe the pressure-flow relationship. We found a quadriphasic pressure-flow relationship with 4 distinct physiological phases. Smaller arterioles demonstrated greater vasodilation during low CPP when compared with large arterioles (P<0.01), whereas vasoconstrictive capacity during high CPP was not significantly different between arterioles (P>0.9). The upper limit of CA was defined by 2 breakpoints. Increases in CPP lead to a point of maximal vasoconstriction of the smallest pial arterioles (upper limit of autoregulation [ULA] 1). Beyond ULA1, only larger arterioles maintain a limited additional vasoconstrictive capacity, extending the buffer for high CPP. Beyond ULA2, vasoconstrictive capacity is exhausted, and all pial arterioles passively dilate. There was substantial intersubject variability, with ranges of 29.2, 47.3, and 50.9 mm Hg for the lower limit, ULA1, and ULA2, respectively. Conclusions We provide new insights into the quadriphasic physiology of CA, differentiating between truly active CA and an extended capacity to buffer increased CPP with progressive failure of CA. In this experimental model, the limits of CA widely varied between subjects.
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Affiliation(s)
- Samuel P Klein
- Department of Neurosurgery University Hospitals Leuven Leuven Belgium
| | | | - Geert Meyfroidt
- Department of Intensive Care Medicine University Hospitals Leuven Leuven Belgium
| | - Bart Depreitere
- Department of Neurosurgery University Hospitals Leuven Leuven Belgium
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8
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Tas J, Beqiri E, van Kaam RC, Czosnyka M, Donnelly J, Haeren RH, van der Horst ICC, Hutchinson PJ, van Kuijk SMJ, Liberti AL, Menon DK, Hoedemaekers CWE, Depreitere B, Smielewski P, Meyfroidt G, Ercole A, Aries MJH. Targeting Autoregulation-Guided Cerebral Perfusion Pressure after Traumatic Brain Injury (COGiTATE): A Feasibility Randomized Controlled Clinical Trial. J Neurotrauma 2021; 38:2790-2800. [PMID: 34407385 DOI: 10.1089/neu.2021.0197] [Citation(s) in RCA: 91] [Impact Index Per Article: 30.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Managing traumatic brain injury (TBI) patients with a cerebral perfusion pressure (CPP) near to the cerebral autoregulation (CA)-guided "optimal" CPP (CPPopt) value is associated with improved outcome and might be useful to individualize care, but has never been prospectively evaluated. This study evaluated the feasibility and safety of CA-guided CPP management in TBI patients requiring intracranial pressure monitoring and therapy (TBIicp patients). The CPPopt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) parallel two-arm feasibility trial took place in four tertiary centers. TBIicp patients were randomized to either the Brain Trauma Foundation (BTF) guideline CPP target range (control group) or to the individualized CA-guided CPP targets (intervention group). CPP targets were guided by six times daily software-based alerts for up to 5 days. The primary feasibility end-point was the percentage of time with CPP concordant (±5 mm Hg) with the set CPP targets. The main secondary safety end-point was an increase in therapeutic intensity level (TIL) between the control and intervention group. Twenty-eight patients were randomized to the control and 32 patients to the intervention group. CPP in the intervention group was in the target range for 46.5% (interquartile range, 41.2-58) of the monitored time, significantly higher than the feasibility target specified in the published protocol (36%; p < 0.001). There were no significant differences between groups for TIL or for other safety end-points. Conclusively, targeting an individual and dynamic CA-guided CPP is feasible and safe in TBIicp patients. This encourages a prospective trial powered for clinical outcomes.
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ruud C van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Roel H Haeren
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Neurosurgery, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Analisa L Liberti
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Anaesthesia and Intensive Care, San Carlo Borromeo Hospital, Milan, Italy
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | | | - Bart Depreitere
- Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Marcel J H Aries
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
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Cramer SW, Carter RE, Aronson JD, Kodandaramaiah SB, Ebner TJ, Chen CC. Through the looking glass: A review of cranial window technology for optical access to the brain. J Neurosci Methods 2021; 354:109100. [PMID: 33600850 DOI: 10.1016/j.jneumeth.2021.109100] [Citation(s) in RCA: 34] [Impact Index Per Article: 11.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/22/2020] [Revised: 02/07/2021] [Accepted: 02/09/2021] [Indexed: 02/07/2023]
Abstract
Deciphering neurologic function is a daunting task, requiring understanding the neuronal networks and emergent properties that arise from the interactions among single neurons. Mechanistic insights into neuronal networks require tools that simultaneously assess both single neuron activity and the consequent mesoscale output. The development of cranial window technologies, in which the skull is thinned or replaced with a synthetic optical interface, has enabled monitoring neuronal activity from subcellular to mesoscale resolution in awake, behaving animals when coupled with advanced microscopy techniques. Here we review recent achievements in cranial window technologies, appraise the relative merits of each design and discuss the future research in cranial window design.
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Affiliation(s)
- Samuel W Cramer
- Department of Neurosurgery, University of Minnesota, 420 Delaware St SE, Mayo D429, MMC 96, Twin Cities, Minneapolis, MN, 55455, USA
| | - Russell E Carter
- Department of Neuroscience, University of Minnesota, Twin Cities, Room 421, 2001 Sixth Street S.E., Minneapolis, MN, 55455 MN, USA
| | - Justin D Aronson
- Department of Neuroscience, University of Minnesota, Twin Cities, Room 421, 2001 Sixth Street S.E., Minneapolis, MN, 55455 MN, USA
| | - Suhasa B Kodandaramaiah
- Department of Mechanical Engineering, University of Minnesota, Twin Cities, MN, USA; Department of Biomedical Engineering, University of Minnesota, Twin Cities, MN, USA; Graduate Program in Neuroscience, University of Minnesota, Twin Cities, MN, USA
| | - Timothy J Ebner
- Department of Neuroscience, University of Minnesota, Twin Cities, Room 421, 2001 Sixth Street S.E., Minneapolis, MN, 55455 MN, USA.
| | - Clark C Chen
- Department of Neurosurgery, University of Minnesota, 420 Delaware St SE, Mayo D429, MMC 96, Twin Cities, Minneapolis, MN, 55455, USA.
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Real-time flow impedance evaluation method for ultra-fast early detection of aneurysmal diseases. Biomed Signal Process Control 2021. [DOI: 10.1016/j.bspc.2020.102256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022]
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Depreitere B, Citerio G, Smith M, Adelson PD, Aries MJ, Bleck TP, Bouzat P, Chesnut R, De Sloovere V, Diringer M, Dureanteau J, Ercole A, Hawryluk G, Hawthorne C, Helbok R, Klein SP, Neumann JO, Robba C, Steiner L, Stocchetti N, Taccone FS, Valadka A, Wolf S, Zeiler FA, Meyfroidt G. Cerebrovascular Autoregulation Monitoring in the Management of Adult Severe Traumatic Brain Injury: A Delphi Consensus of Clinicians. Neurocrit Care 2021; 34:731-738. [PMID: 33495910 PMCID: PMC8179892 DOI: 10.1007/s12028-020-01185-x] [Citation(s) in RCA: 58] [Impact Index Per Article: 19.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2020] [Accepted: 12/31/2020] [Indexed: 12/12/2022]
Abstract
BACKGROUND Several methods have been proposed to measure cerebrovascular autoregulation (CA) in traumatic brain injury (TBI), but the lack of a gold standard and the absence of prospective clinical data on risks, impact on care and outcomes of implementation of CA-guided management lead to uncertainty. AIM To formulate statements using a Delphi consensus approach employing a group of expert clinicians, that reflect current knowledge of CA, aspects that can be implemented in TBI management and CA research priorities. METHODS A group of 25 international academic experts with clinical expertise in the management of adult severe TBI patients participated in this consensus process. Seventy-seven statements and multiple-choice questions were submitted to the group in two online surveys, followed by a face-to-face meeting and a third online survey. Participants received feedback on average scores and the rationale for resubmission or rephrasing of statements. Consensus on a statement was defined as agreement of more than 75% of participants. RESULTS Consensus amongst participants was achieved on the importance of CA status in adult severe TBI pathophysiology, the dynamic non-binary nature of CA impairment, its association with outcome and the inadvisability of employing universal and absolute cerebral perfusion pressure targets. Consensus could not be reached on the accuracy, reliability and validation of any current CA assessment method. There was also no consensus on how to implement CA information in clinical management protocols, reflecting insufficient clinical evidence. CONCLUSION The Delphi process resulted in 25 consensus statements addressing the pathophysiology of impaired CA, and its impact on cerebral perfusion pressure targets and outcome. A research agenda was proposed emphasizing the need for better validated CA assessment methods as well as the focused investigation of the application of CA-guided management in clinical care using prospective safety, feasibility and efficacy studies.
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Affiliation(s)
- B Depreitere
- Neurosurgery, University Hospitals Leuven, Herestraat 49, B-3000, Leuven, Belgium.
| | - G Citerio
- Intensive Care Medicine, School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy
| | - M Smith
- Neurocritical Care Unit, National Hospital for Neurology and Neurosurgery, University College London, London, UK
| | - P David Adelson
- Barrow Neurological Institute At Phoenix Childrens Hospital, Department of Child Health/Neurosurgery, University of Arizona College of Medicine, Tucson, AZ, USA
- Department of Neurosurgery, Mayo Clinic School of Medicine, School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - M J Aries
- Department of Intensive Care, Maastricht University Medical Center, University of Maastricht, Maastricht, The Netherlands
| | - T P Bleck
- Davee Department of Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL, USA
| | - P Bouzat
- Grenoble Alps Trauma Center, Department of Anesthesiology and Intensive Care Medicine, Grenoble University Hospital, Grenoble, France
| | - R Chesnut
- Department of Neurological Surgery, Harborview Medical Center, University of Washington, Seattle, WA, USA
| | - V De Sloovere
- Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - M Diringer
- Department of Neurology, Barnes-Jewish Hospital, Washington University School of Medicine, St. Louis, MO, USA
| | - J Dureanteau
- Université Paris Sud - Hôpitaux Universitaires Paris-Sud, Paris, France
| | - A Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - G Hawryluk
- Section of Neurosurgery, University of Manitoba, Winnipeg, MB, Canada
| | - C Hawthorne
- Head and Neck Anaesthesia and Neurocritical Care, Institute of Neurological Sciences, Glasgow, UK
| | - R Helbok
- Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - S P Klein
- Neurosurgery, University Hospital Brussels, Brussels, Belgium
| | - J O Neumann
- Department of Neurosurgery, University of Heidelberg, Heidelberg, Germany
| | - C Robba
- Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genova, Italy
| | - L Steiner
- Anesthesiology, University Hospital Basel, Basel, Switzerland
- Department of Clinical Research, University of Basel, Basel, Switzerland
| | - N Stocchetti
- Department of Physiopathology and Transplant, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - F S Taccone
- Department of Intensive Care, Hôpital Erasme, Université Libre de Bruxelles (ULB), Brussels, Belgium
| | - A Valadka
- Department of Neurosurgery, Virginia Commonwealth University, Richmond, VA, USA
| | - S Wolf
- Department of Neurosurgery, University Hospital Berlin Charité, Berlin, Germany
| | - F A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Canada
| | - G Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Froese L, Dian J, Batson C, Gomez A, Unger B, Zeiler FA. Cerebrovascular Response to Propofol, Fentanyl, and Midazolam in Moderate/Severe Traumatic Brain Injury: A Scoping Systematic Review of the Human and Animal Literature. Neurotrauma Rep 2020; 1:100-112. [PMID: 33251530 PMCID: PMC7685293 DOI: 10.1089/neur.2020.0040] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous propofol, fentanyl, and midazolam are utilized commonly in critical care for metabolic suppression and anesthesia. The impact of propofol, fentanyl, and midazolam on cerebrovasculature and cerebral blood flow (CBF) is unclear in traumatic brain injury (TBI) and may carry important implications, as care is shifting to focus on cerebrovascular reactivity monitoring/directed therapies. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/CBF effects of propofol, fentanyl, and midazolam in human patients with moderate/severe TBI and animal models with TBI. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to May 2020 was performed. All articles were included pertaining to the administration of propofol, fentanyl, and midazolam, in which the impact on CBF/cerebral vasculature was recorded. We identified 14 studies: 8 that evaluated propofol, 5 that evaluated fentanyl, and 2 that evaluated midazolam. All studies suffered from significant limitations, including: small sample size, and heterogeneous design and measurement techniques. In general, there was no significant change seen in CBF/cerebrovascular response to administration of propofol, fentanyl, or midazolam during experiments where PCO2 and mean arterial pressure (MAP) were controlled. This review highlights the current knowledge gap surrounding the impact of commonly utilized sedative drugs in TBI care. This work supports the need for dedicated studies, both experimental and human-based, evaluating the impact of these drugs on CBF and cerebrovascular reactivity/response in TBI.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Dian
- Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Carleen Batson
- Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bertram Unger
- Section of Critical Care, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Section of Neurosurgery, Department of Surgery, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Anatomy and Cell Science, Department of Medicine, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada.,Division of Anesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Froese L, Dian J, Gomez A, Unger B, Zeiler FA. The cerebrovascular response to norepinephrine: A scoping systematic review of the animal and human literature. Pharmacol Res Perspect 2020; 8:e00655. [PMID: 32965778 PMCID: PMC7510331 DOI: 10.1002/prp2.655] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Intravenous norepinephrine (NE) is utilized commonly in critical care for cardiovascular support. NE's impact on cerebrovasculature is unclear and may carry important implications during states of critical neurological illness. The aim of the study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of NE. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019 was performed. All manuscripts pertaining to the administration of NE, in which the impact on CBF/cerebral vasculature was recorded, were included. We identified 62 animal studies and 26 human studies. Overall, there was a trend to a direct vasoconstriction effect of NE on the cerebral vasculature, with conflicting studies having demonstrated both increases and decreases in regional CBF (rCBF) or global CBF. Healthy animals and those undergoing cardiopulmonary resuscitation demonstrated a dose-dependent increase in CBF with NE administration. However, animal models and human patients with acquired brain injury had varied responses in CBF to NE administration. The animal models indicate an increase in cerebral vasoconstriction with NE administration through the alpha receptors in vessels. Global and rCBF during the injection of NE displays a wide variation depending on treatment and model/patient.
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Affiliation(s)
- Logan Froese
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
| | - Joshua Dian
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Alwyn Gomez
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Bertram Unger
- Section of Critical CareDepartment of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Frederick A. Zeiler
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Centre on AgingUniversity of ManitobaWinnipegCanada
- Division of AnaesthesiaDepartment of MedicineAddenbrooke’s HospitalUniversity of CambridgeCambridgeUK
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Klein SP, Fieuws S, Meyfroidt G, Depreitere B. Effects of Norepinephrine, Propofol, and Hemoglobin Concentration on Dynamic Measurements of Cerebrovascular Reactivity in Acute Brain Injury. J Neurotrauma 2020; 38:506-512. [PMID: 32611275 DOI: 10.1089/neu.2020.7160] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023] Open
Abstract
Effects of treatment-associated variables on cerebrovascular autoregulation (CA) in acute brain injury patients remain unclear. As deficient CA is associated with worse outcomes and ideas about CA-steered management are emerging, this question is relevant. We investigated effects of norepinephrine and propofol infusion rates and hemoglobin concentration on dynamic measurements of cerebrovascular reactivity as surrogate for CA. A retrospective analysis of 91 traumatic brain injury (TBI) and 13 stroke patients admitted to the intensive care unit (ICU) of the Leuven University Hospitals was performed. Low-resolution autoregulation index (LAx) and high-frequency pressure reactivity index (PRx) were calculated as measurements of cerebrovascular reactivity. Data was binned into 5-, 15-, and 60-min intervals. Bivariate time-series analysis using lagged cross-correlations were calculated after pre-whitening and differencing. Linear mixed models evaluated effects of age, gender, cardiovascular risk, brain comorbidity, Glasgow Coma Scale (GCS), pupil reactivity, and type of injury. Median dose of norepinephrine, propofol and hemoglobin concentration was 7.8 μg/kg/h (Q1 3.6-Q3 13.8), 3 mg/kg/h (Q1 1.9-Q3 4.3), and 9.2 g·dL-1 (Q1 8.2-Q3 10.5), respectively. Mean cross-correlations for 24 lags were close to zero and not significant for all variables. No significant differences as function of age, gender, cardiovascular risk, brain comorbidity, GCS, pupil reactivity, and type of injury were found. Dynamic intracranial pressure-based measurements of cerebrovascular reactivity in acute brain injured patients are not affected by gradually adjusted norepinephrine or propofol infusion rates or slow changes in hemoglobin concentration within the typical ranges during ICU admission. Future trials on cerebrovascular reactivity-steered management and treatment of CA impairment may not have to take these variables into account.
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Affiliation(s)
- Samuel P Klein
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Steffen Fieuws
- Leuven Biostatistics and Statistical Bioinformatics Centre (L-BioStat), KULeuven, Leuven, Belgium
| | - Geert Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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