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Haberl H, Unterberg M, Adamzik M, Hagedorn A, Wolf A. [Current Aspects of Intensive Medical Care for Traumatic Brain Injury - Part 1 - Primary Treatment Strategies, Haemodynamic Management and Multimodal Monitoring]. Anasthesiol Intensivmed Notfallmed Schmerzther 2024; 59:450-465. [PMID: 39074790 DOI: 10.1055/a-2075-9351] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/31/2024]
Abstract
This two-part article deals with the intensive medical care of traumatic brain injury. Part 1 addresses the primary treatment strategy, haemodynamic management and multimodal monitoring, Part 2 secondary treatment strategies, long-term outcome, neuroprognostics and chronification. Traumatic brain injury is a complex clinical entity with a high mortality rate. The primary aim is to maintain homeostasis based on physiological targeted values. In addition, further therapy must be geared towards intracranial pressure. In addition to this, there are other monitoring options that appear sensible from a pathophysiological point of view with appropriate therapy adjustment. However, there is still a lack of data on their effectiveness. A further aspect is the inflammation of the cerebrum with the "cross-talk" of the organs, which has a significant influence on further intensive medical care.
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Sorrentino ZA, Lucke-Wold BP, Laurent D, Quintin SS, Hoh BL. Interventional Treatment of Symptomatic Vasospasm in the Setting of Traumatic Brain Injury: A Systematic Review of Reported Cases. World Neurosurg 2024; 183:45-55. [PMID: 38043741 DOI: 10.1016/j.wneu.2023.11.135] [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: 08/19/2023] [Revised: 11/27/2023] [Accepted: 11/28/2023] [Indexed: 12/05/2023]
Abstract
Traumatic subarachnoid hemorrhage (tSAH) is frequently comorbid with traumatic brain injury (TBI) and may induce secondary injury through vascular changes such as vasospasm and subsequent delayed cerebral ischemia (DCI). While aneurysmal SAH is well studied regarding vasospasm and DCI, less is known regarding tSAH and the prevalence of vasospasm and DCI, the consequences of vasospasm in this setting, when treatment is indicated, and which management strategies should be implemented. In this article, a systematic review of the literature that was conducted for cases of symptomatic vasospasm in patients with TBI is reported, association with tSAH is reported, risk factors for vasospasm and DCI are summarized, and commonalities in diagnosis and management are discussed. Clinical characteristics and treatment outcomes of 38 cases across 20 studies were identified in which patients with TBI with vasospasm underwent medical or endovascular management. Of the patients with data available for each category, the average age was 48.7 ± 20.3 years (n = 31), the Glasgow Coma Scale score at presentation was 10.6 ± 4.5 (n = 35), and 100% had tSAH (n = 29). Symptomatic vasospasm indicative of DCI was diagnosed on average at postinjury day 8.4 ± 3.0 days (n = 30). Of the patients, 56.6% (n = 30) had a new ischemic change associated with vasospasm confirming DCI. Treatment strategies are discussed, with 11 of 12 endovascularly treated and 19 of 26 medically treated patients surviving to discharge. tSAH is associated with vasospasm and DCI in moderate and severe TBI, and patients with clinical and radiographic evidence of symptomatic vasospasm and subsequent DCI may benefit from endovascular or medical management strategies.
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Affiliation(s)
- Zachary A Sorrentino
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA.
| | - Brandon P Lucke-Wold
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Dimitri Laurent
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
| | - Stephan S Quintin
- University of Florida College of Medicine, Gainesville, Florida, USA
| | - Brian L Hoh
- University of Florida College of Medicine, Gainesville, Florida, USA; Department of Neurosurgery, University of Florida College of Medicine, Gainesville, Florida, USA
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Gelormini C, Ioannoni E, Scavone A, Pisapia L, Signorelli F, Montano N, Piastra M, Caricato A. Hyperemia in head injury: can transcranial doppler help to personalize therapies for intracranial hypertension? Front Neurol 2023; 14:1259180. [PMID: 38033776 PMCID: PMC10686491 DOI: 10.3389/fneur.2023.1259180] [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] [Received: 07/15/2023] [Accepted: 10/24/2023] [Indexed: 12/02/2023] Open
Abstract
Introduction An increase in cerebral blood flow is frequent after traumatic brain injury (TBI) and can lead to brain swelling and refractory intracranial hypertension. We hypothesized that Transcranial EcoDoppler (TCD) monitoring could be useful to detect the cause of intracranial hypertension in these patients. Our main objective was to investigate if the increase of velocity in the middle cerebral artery (MCA) on TCD could be associated with intracranial hypertension. Methods We retrospectively studied TBI patients consecutively monitored with TCD. Hyperemia was defined as MCA mean velocity higher than 80 cm/s. Intracranial hypertension was considered when hyperosmolar therapy, hyperventilation, or deep sedation was used. Results We found hyperemia in 40 patients out of 118 (33.9%). On average, it started at day 2.1 ± 0.9 from admission and significantly increased (MCA velocity at day 1: 74 ± 25 cm/s vs. 109 ± 36 cm/s at day 4; p < 0.001). Intracranial hypertension was significantly associated with hyperemia, occurring in 92.5% of hyperemic and 51.3% of non-hyperemic patients (p < 0.001). Moreover, we found that hyperemia preceded severe intracranial hypertension (p < 0.0001). In a logistic regression model, hyperemia was the only variable significantly correlated with intracranial hypertension (OR 10.64; p < 0.001). Discussion Hyperemia was frequent in our population of TBI patients and preceded intracranial hypertension. TCD monitoring, if performed on a daily regular basis, can be a useful method to detect this phenomenon and to guide the therapy. It could be a tool for a cause-oriented therapy of intracranial hypertension.
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Affiliation(s)
- Camilla Gelormini
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Eleonora Ioannoni
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Angela Scavone
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Luca Pisapia
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Francesco Signorelli
- Neurosurgery Section, Department of Neuroscience, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
| | - Nicola Montano
- Neurosurgery Section, Department of Neuroscience, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Neurosurgery Section, Department of Neuroscience, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Marco Piastra
- Pediatric ICU and Trauma Center, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
| | - Anselmo Caricato
- Neurointensive Care Unit, Department of Anesthesiology, Intensive Care and Emergency Medicine, Fondazione Policlinico Universitario “Agostino Gemelli” IRCCS, Rome, Italy
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Università Cattolica del Sacro Cuore, Rome, Italy
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Riordan K, Mamaril-Davis J, Aguilar-Salinas P, Dumont TM, Weinand ME. Outcomes following therapeutic intervention of post-traumatic vasospasm: A systematic review and meta-analysis. Clin Neurol Neurosurg 2023; 232:107877. [PMID: 37441930 DOI: 10.1016/j.clineuro.2023.107877] [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: 04/06/2023] [Revised: 06/21/2023] [Accepted: 06/25/2023] [Indexed: 07/15/2023]
Abstract
BACKGROUND Vasospasm occurrence following traumatic brain injury may impact neurologic and functional recovery of patients, yet treatment of post-traumatic vasospasm (PTV) has not been well documented. This systematic review and meta-analysis aims to assess the current evidence regarding favorable outcome as measured by Glasgow Outcome Scale (GOS) scores following treatment of PTV. METHODS A systematic review of PubMed, Ovid MEDLINE, and Ovid EMBASE was conducted following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Included manuscripts were methodically scrutinized for quality; occurrence of PTV; rate of favorable outcome following each treatment modality; and follow-up duration. Treatments evaluated were calcium channel blockers (CCBs), endovascular intervention, and dopamine-induced hypertension. Outcomes were compared via the random-effects analysis. RESULTS Fourteen studies with 1885 PTV patients were quantitatively analyzed: 982 patients who received tailored therapeutic intervention and 903 patients who did not receive tailored therapy. For patients undergoing treatment, the rate of favorable outcome was 57.3 % (500/872 patients; 95 % CI 54.1 - 60.6 %) following administration of CCBs, 94.1 % (16/17 patients; 95 % CI 82.9 - 100.0 %) following endovascular intervention, and 54.8 % (51/93 patients; 95 % CI 44.7 - 65.0 %) following dopamine-induced hypertension. Of note, the endovascular group had the highest rate of favorable outcome but was also the smallest sample size (n = 17). Patients who received tailored therapeutic intervention for PTV had a higher rate of favorable outcome than patients who did not receive tailored therapy: 57.7 % (567/982 patients; 95 % CI 54.1 - 60.8 %) versus 52.0 % (470/903 patients; 95 % CI 48.8 - 55.3 %), respectively. CONCLUSIONS The available data suggests that tailored therapeutic intervention of PTV results in a favorable outcome. While endovascular intervention of PTV had the highest rate of favorable outcome, both CCB administration and dopamine-induced hypertension had similar lower rates of favorable outcome.
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Affiliation(s)
- Katherine Riordan
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - James Mamaril-Davis
- College of Medicine, University of Arizona College of Medicine - Tucson, Tucson, AZ, United States
| | - Pedro Aguilar-Salinas
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Travis M Dumont
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States
| | - Martin E Weinand
- Department of Neurosurgery, Banner University Medical Center / University of Arizona, Tucson, AZ, United States.
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Tamagnone FM, Cheong I, Luna E, Previgliano I, Otero Castro V. Ultrasound-guided cerebral resuscitation in patients with severe traumatic brain Injury. J Clin Monit Comput 2023; 37:359-363. [PMID: 36454340 DOI: 10.1007/s10877-022-00954-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2022] [Accepted: 11/24/2022] [Indexed: 12/04/2022]
Abstract
Traumatic brain injury (TBI) is a worldwide public health concern given its significant morbidity and mortality, years of potential life lost, reduced quality of life and elevated healthcare costs. The primary injury occurs at the moment of impact, but secondary injuries might develop as a result of brain hemodynamic abnormalities, hypoxia, and hypotension. The cerebral edema and hemorrhage of the injured tissues causes a decrease in cerebral perfusion pressure (CPP), which leads to higher risk of cerebral ischemia, herniation and death. In this setting, our role as physicians is to minimize damage by the optimization of the CPP and therefore to reduce mortality and improve neurological outcomes. Performing a transcranial doppler ultrasound (TCD) allows to estimate cerebral blood flow velocities and identify states of low flow and high resistance. We propose to include TCD as an initial assessment and further monitoring tool for resuscitation guidance in patients with severe TBI. We present an Ultrasound-Guided Cardio-cerebral Resuscitation (UGCeR) protocol in Patients with Severe TBI.
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Affiliation(s)
| | - Issac Cheong
- Argentinian Critical Care Ultrasonography Association (ASARUC), Buenos Aires, Argentina.
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina.
- Department of critical care medicine, Sanatorio De los Arcos, Juan B. Justo 909, Buenos Aires, Argentina.
| | - Ezequiel Luna
- Department of critical care medicine, Sanatorio Guemes, Buenos Aires, Argentina
| | - Ignacio Previgliano
- Maimonides University, Buenos aires, Argentina
- Hospital General de Agudos J. A. Fernández, Buenos Aires, Argentina
| | - Victoria Otero Castro
- Department of critical care medicine, Sanatorio De los Arcos, Buenos Aires, Argentina
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Liao J, Zhang M, Shi Z, Lu H, Wang L, Fan W, Tong X, Yan H. Improving the Function of Meningeal Lymphatic Vessels to Promote Brain Edema Absorption after Traumatic Brain Injury. J Neurotrauma 2023; 40:383-394. [PMID: 36106596 DOI: 10.1089/neu.2022.0150] [Citation(s) in RCA: 16] [Impact Index Per Article: 16.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023] Open
Abstract
Brain edema is the most common and fatal complication after traumatic brain injury (TBI). Meningeal lymphatic vessels (MLVs) are the conduits that transport cerebrospinal fluid (CSF) and macromolecules to deep extracranial cervical lymph nodes (dCLNs). After TBI, the drainage function of MLVs can become impaired. However, the scenario in which the improvement of the function of MLVs can promote brain edema absorption after TBI has not been reported. Therefore, the purpose of this study was to investigate the effects of ketoprofen, 9-cis retinoic acid (RA) and vascular endothelial cell growth factor-C (VEGF-C), which promote the proliferation of peripheral lymphatic vessels, on the cerebellar medullary cistern injection of TBI rats, as well as their mechanism of action on brain edema after TBI. In the experiment, we found that ketoprofen, 9-cisRA, and VEGF-C can improve the function of MLVs, promote the extracranial drainage of CSF and the absorption of brain edema, weaken the neuroinflammatory response, reduce reactive oxygen species (ROS) production, maintain the structural integrity of MLVs, and improve neurological function. In addition, ketoprofen, 9-cisRA, and VEGF-C upregulated the lymphatic-specific proteins VEGF receptor (VEGFR)3, PROX1, forkhead box protein C2 (FOXC2), and lymphatic vessel endothelial hyaluronan receptor 1 (LYVE1). These results indicate that ketoprofen, 9-cisRA, and VEGF-C may maintain the integrity of the meningeal lymphatic wall and promote lymphatic proliferation by upregulating the expression of lymphatic vessel-specific proteins, improve meningeal lymphatic function after TBI, promote CSF drainage and brain edema absorption, reduce the immune response of the nervous system, and reduce ROS formation, thereby improving prognoses. These findings may provide new ideas for the treatment of brain edema after TBI.
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Affiliation(s)
- Jianwen Liao
- Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China.,Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Mingchao Zhang
- Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Zichuan Shi
- Department of Neurology, Tianjin Academy of Traditional Chinese Medicine Affiliated Hospital, Tianjin, China
| | - Hao Lu
- Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China
| | - Lichen Wang
- Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China
| | - Weijia Fan
- Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China.,Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Xiaoguang Tong
- Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China.,Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China
| | - Hua Yan
- Tianjin Huanhu Hospital, Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin Neurosurgical Institute, Tianjin, China.,Clinical College of Neurology, Neurosurgery, and Neurorehabilitation, Tianjin Medical University, Tianjin, China
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7
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Cerebrovascular injuries in traumatic brain injury. Clin Neurol Neurosurg 2022; 223:107479. [DOI: 10.1016/j.clineuro.2022.107479] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2022] [Revised: 09/22/2022] [Accepted: 10/13/2022] [Indexed: 11/19/2022]
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8
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Towards integration of transcranial Doppler in the management of severe TBI in LICs and LMICs: A cohort retrospective study. INTERDISCIPLINARY NEUROSURGERY 2022. [DOI: 10.1016/j.inat.2021.101460] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
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9
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Vasospasm Surveillance by a Simplified Transcranial Doppler Protocol in Traumatic Brain Injury. World Neurosurg 2022; 164:e318-e325. [PMID: 35504479 DOI: 10.1016/j.wneu.2022.04.108] [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: 03/28/2022] [Revised: 04/24/2022] [Accepted: 04/25/2022] [Indexed: 11/24/2022]
Abstract
OBJECTIVE To detect post-traumatic vasospasm in patients with traumatic brain injury (TBI), we implemented a simplified transcranial Doppler (TCD) surveillance protocol in a neurointensive care setting. In this study, we evaluate the yield of this protocol. METHODS Adult patients with TBI admitted to the neurointensive care unit were examined with TCD by 2 intensive care nurses trained in TCD examinations. Flow velocities of the middle cerebral arteries were recorded. TCD suspected vasospasm was defined as the mean flow velocity >120 cm/s, and when detected, the protocol recommended a supplementary computed tomography angiography. The rate of detection of TCD suspected vasospasm and the subsequent rate of radiological diagnosis of vasospasm were recorded. In multivariate logistic regression analysis, we evaluated age, initial Glasgow Coma Scale, craniotomy, and decompressive craniectomy as potential predictors of developing increased TCD velocity. RESULTS A total of 84 patients with TBI with a median initial Glasgow Coma Scale score of 6 were examined by TCD. TCD suspected vasospasm was found in the middle cerebral arteries of 18% of examined patients. Two-thirds of patients with TCD suspected vasospasm were investigated with a subsequent computed tomography angiography, and 80% of these patients received a radiological diagnosis of vasospasm. In logistic regression analysis, decompressive craniectomy was significantly associated with increased risk of developing TCD suspected vasospasm (odds ratio: 11.57, 95% confidence interval: 2.59-51.73, P = 0.001). CONCLUSIONS The implementation of a simplified TCD surveillance protocol in a neurointensive care setting yielded an 18% detection rate of TCD suspected vasospasm. In our cohort of patients with TBI, decompressive craniectomy was associated with increased risk of developing TCD suspected vasospasm.
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10
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Mainali S, Cardim D, Sarwal A, Merck LH, Yeatts SD, Czosnyka M, Shutter L. Prolonged Automated Robotic TCD Monitoring in Acute Severe TBI: Study Design and Rationale. Neurocrit Care 2022; 37:267-275. [PMID: 35381966 DOI: 10.1007/s12028-022-01483-6] [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: 12/01/2021] [Accepted: 03/01/2022] [Indexed: 10/18/2022]
Abstract
BACKGROUND Transcranial Doppler ultrasonography (TCD) is a portable, bedside, noninvasive diagnostic tool used for the real-time assessment of cerebral hemodynamics. Despite the evident utility of TCD and the ability of this technique to function as a stethoscope to the brain, its use has been limited to specialized centers because of the dearth of technical and clinical expertise required to acquire and interpret the cerebrovascular parameters. Additionally, the conventional pragmatic episodic TCD monitoring protocols lack dynamic real-time feedback to guide time-critical clinical interventions. Fortunately, with the recent advent of automated robotic TCD technology in conjunction with the automated software for TCD data processing, we now have the technology to automatically acquire TCD data and obtain clinically relevant information in real-time. By obviating the need for highly trained clinical personnel, this technology shows great promise toward a future of widespread noninvasive monitoring to guide clinical care in patients with acute brain injury. METHODS Here, we describe a proposal for a prospective observational multicenter clinical trial to evaluate the safety and feasibility of prolonged automated robotic TCD monitoring in patients with severe acute traumatic brain injury (TBI). We will enroll patients with severe non-penetrating TBI with concomitant invasive multimodal monitoring including, intracranial pressure, brain tissue oxygenation, and brain temperature monitoring as part of standard of care in centers with varying degrees of TCD availability and experience. Additionally, we propose to evaluate the correlation of pertinent TCD-based cerebral autoregulation indices such as the critical closing pressure, and the pressure reactivity index with the brain tissue oxygenation values obtained invasively. CONCLUSIONS The overarching goal of this study is to establish safety and feasibility of prolonged automated TCD monitoring for patients with TBI in the intensive care unit and identify clinically meaningful and pragmatic noninvasive targets for future interventions.
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Affiliation(s)
- Shraddha Mainali
- Department of Neurology, Virginial Commonwealth University, Richmond, VA, USA.
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Aarti Sarwal
- Department of Neurology, Wake Forest School of Medicine, Winston Salem, NC, USA
| | - Lisa H Merck
- Departments of Emergency Medicine and Neurology, University of Florida College of Medicine, Gainesville, FL, USA
| | - Sharon D Yeatts
- Department of Public Health Sciences, Medical University of South Carolina, Charleston, SC, USA
| | - Marek Czosnyka
- Brain Physics Laboratory, Neurosurgical Unit, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Lori Shutter
- Department of Critical Care Medicine, Neurology, and Neurosurgery, University of Pittsburgh, Pittsburgh, PA, USA
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Cerebral Pulsatility Index and In-Hospital Mortality in Chinese Patients with Traumatic Brain Injury: A Retrospective Cohort Study. J Clin Med 2022; 11:jcm11061559. [PMID: 35329885 PMCID: PMC8950001 DOI: 10.3390/jcm11061559] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/15/2022] [Revised: 03/08/2022] [Accepted: 03/09/2022] [Indexed: 02/04/2023] Open
Abstract
There are limited studies on the relationship between the vascular transcranial Doppler (TCD) pulsatility index (PI) and in-hospital mortality in patients with traumatic brain injury (TBI). To address this issue, we conducted this study to explore whether, in newly diagnosed Chinese TBI patients, the PI is an independent predictor of the in-hospital mortality rate after adjusting for other covariates. This study is a retrospective cohort study. From 24 March 2019 to 24 January 2020, we recruited 144 Chinese patients with newly diagnosed TBI from a Chinese hospital. The independent variable was the PI, and the dependent variable was in-hospital mortality in TBI patients. The relationship between the PI and in-hospital mortality in TBI patients was nonlinear and had an inflection point of 1.11. In the multivariate analysis, after adjusting for potential confounders, the effect sizes and confidence intervals per additional 0.1 units on the left and right sides of the inflection point were 4.09 (1.30–12.83) and 1.42 (0.93–2.17). The relationship between the PI and in-hospital mortality was nonlinear. The PI was positively related with in-hospital mortality when the PI was less than 1.11.
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12
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Loggini A, Kass-Hout T, Awad IA, El Ammar F, Kramer CL, Goldenberg FD, Lazaridis C, Mansour A. Case Report: Management of Traumatic Carotid-Cavernous Fistulas in the Acute Setting of Penetrating Brain Injury. Front Neurol 2022; 12:715955. [PMID: 35222224 PMCID: PMC8879509 DOI: 10.3389/fneur.2021.715955] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/27/2021] [Accepted: 11/22/2021] [Indexed: 12/02/2022] Open
Abstract
Traumatic carotid-cavernous fistulas (tCCFs) after penetrating brain injury (PBI) have been uncommonly described in the literature with little guidance on optimal treatment. In this case series, we present two patients with PBI secondary to gunshot wounds to the head who acutely developed tCCFs, and we review the lead-up to diagnosis in addition to the treatment of this condition. We highlight the importance of early cerebrovascular imaging as the clinical manifestations may be limited by poor neurological status and possibly concomitant injury. Definitive treatment should be attempted as soon as possible with embolization of the fistula, flow diversion via stenting of the fistula site, and, finally, vessel sacrifice as possible therapeutic options.
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Affiliation(s)
- Andrea Loggini
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Tareq Kass-Hout
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Issam A. Awad
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Faten El Ammar
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Christopher L. Kramer
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Fernando D. Goldenberg
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Christos Lazaridis
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
| | - Ali Mansour
- Neurosciences Intensive Care Unit, Department of Neurology, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- Section of Neurosurgery, Department of Surgery, University of Chicago Medicine and Biological Sciences, Chicago, IL, United States
- *Correspondence: Ali Mansour
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13
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Current state of high-fidelity multimodal monitoring in traumatic brain injury. Acta Neurochir (Wien) 2022; 164:3091-3100. [PMID: 36260235 PMCID: PMC9705453 DOI: 10.1007/s00701-022-05383-8] [Citation(s) in RCA: 12] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/19/2022] [Accepted: 09/28/2022] [Indexed: 02/01/2023]
Abstract
INTRODUCTION Multimodality monitoring of patients with severe traumatic brain injury (TBI) is primarily performed in neuro-critical care units to prevent secondary harmful brain insults and facilitate patient recovery. Several metrics are commonly monitored using both invasive and non-invasive techniques. The latest Brain Trauma Foundation guidelines from 2016 provide recommendations and thresholds for some of these. Still, high-level evidence for several metrics and thresholds is lacking. METHODS Regarding invasive brain monitoring, intracranial pressure (ICP) forms the cornerstone, and pressures above 22 mmHg should be avoided. From ICP, cerebral perfusion pressure (CPP) (mean arterial pressure (MAP)-ICP) and pressure reactivity index (PRx) (a correlation between slow waves MAP and ICP as a surrogate for cerebrovascular reactivity) may be derived. In terms of regional monitoring, partial brain tissue oxygen pressure (PbtO2) is commonly used, and phase 3 studies are currently ongoing to determine its added effect to outcome together with ICP monitoring. Cerebral microdialysis (CMD) is another regional invasive modality to measure substances in the brain extracellular fluid. International consortiums have suggested thresholds and management strategies, in spite of lacking high-level evidence. Although invasive monitoring is generally safe, iatrogenic hemorrhages are reported in about 10% of cases, but these probably do not significantly affect long-term outcome. Non-invasive monitoring is relatively recent in the field of TBI care, and research is usually from single-center retrospective experiences. Near-infrared spectrometry (NIRS) measuring regional tissue saturation has been shown to be associated with outcome. Transcranial doppler (TCD) has several tentative utilities in TBI like measuring ICP and detecting vasospasm. Furthermore, serial sampling of biomarkers of brain injury in the blood can be used to detect secondary brain injury development. CONCLUSIONS In multimodal monitoring, the most important aspect is data interpretation, which requires knowledge of each metric's strengths and limitations. Combinations of several modalities might make it possible to discern specific pathologic states suitable for treatment. However, the cost-benefit should be considered as the incremental benefit of adding several metrics has a low level of evidence, thus warranting additional research.
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Cardim D, Czosnyka M, Chandrapatham K, Badenes R, Bertuccio A, Corradi F, Donnelly J, Pelosi P, Hutchinson PJ, Robba C. Arterial and Venous Cerebral Blood Flow Velocities and Their Correlation in Healthy Volunteers and Traumatic Brain Injury Patients. J Neurosurg Anesthesiol 2022; 34:e24-e33. [PMID: 32555064 DOI: 10.1097/ana.0000000000000704] [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: 12/12/2019] [Accepted: 05/13/2020] [Indexed: 12/22/2022]
Abstract
BACKGROUND Few studies have explored the cerebral venous compartment or the correlation between venous and arterial cerebral blood flows. We aimed to correlate cerebral blood flow velocities in the arterial (middle cerebral artery) and venous (straight sinus) compartments in healthy volunteers and traumatic brain injury (TBI) patients. In addition, we determined the normative range of these parameters. MATERIALS AND METHODS A total of 122 healthy volunteers and 95 severe TBI patients of both sexes were included and stratified into 3 age groups as follows: group 1 (aged, 18 to 44 y); group 2 (aged, 45 to 64 y); group 3 (older than 65 y). Transcranial Doppler systolic cerebral blood flow velocity, diastolic cerebral blood flow velocity, and mean cerebral blood flow velocity (FVs, FVd, FVm, respectively) were measured in the middle cerebral artery and peak cerebral venous blood flow velocity (FVVs) was measured in the straight sinus. The arteriovenous correlation was assessed on the basis of a positive relationship between FVs and FVVs. RESULTS There was an arteriovenous correlation (FVs vs. FVVs) in healthy volunteers (R=0.39, P<0.0001). We found no arteriovenous correlation in the TBI cohort overall, but FVs and FVVs were correlated in age group 1 (R=0.28, P=0.05) and in males (R=0.29, P=0.01). In healthy volunteers, FVs and FVm were significantly higher in males compared with females; and FVs, FVm, FVd, FVVs all increased across the age spectrum. There were no significant differences in any of these parameters in TBI patients. CONCLUSIONS There are age and sex differences in arterial and venous cerebral blood flow velocities in healthy volunteers. Arteriovenous correlation is present in healthy volunteers but absent in TBI patients.
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Affiliation(s)
- Danilo Cardim
- Brain Physics Laboratory
- Department of Neurology and Neurotherapeutics, University of Texas Southwestern Medical Center
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX
| | - Marek Czosnyka
- Brain Physics Laboratory
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | | | - Rafael Badenes
- University of Valencia Hospital Clinic, Anesthesiology and Surgical-trauma Intensive Care, Valencia, Spain
| | | | | | - Joseph Donnelly
- Brain Physics Laboratory
- Department of Anesthesiology, University of Auckland, Auckland, New Zealand
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, UK
| | - Chiara Robba
- Brain Physics Laboratory
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology, University of Genoa, Genoa
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15
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Gomez A, Batson C, Froese L, Sainbhi AS, Zeiler FA. Utility of Transcranial Doppler in Moderate and Severe Traumatic Brain Injury: A Narrative Review of Cerebral Physiologic Metrics. J Neurotrauma 2021; 38:2206-2220. [PMID: 33554739 PMCID: PMC8328046 DOI: 10.1089/neu.2020.7523] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022] Open
Abstract
Since its creation in the 1980s, transcranial Doppler (TCD) has provided a method of non-invasively monitoring cerebral physiology and has become an invaluable tool in neurocritical care. In this narrative review, we examine the role TCD has in the management of the moderate and severe traumatic brain injury (TBI) patient. We examine the principles of TCD and the ways in which it has been applied to gain insight into cerebral physiology following TBI, as well as explore the clinical evidence supporting these applications. Its usefulness as a tool to non-invasively determine intracranial pressure, detect post-traumatic vasospasm, predict patient outcome, and assess the state of cerebral autoregulation are all explored.
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Affiliation(s)
- Alwyn Gomez
- Department of Surgery, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Canada
| | | | - Frederick Adam Zeiler
- Department of Surgery, University of Manitoba, Winnipeg, Canada
- Department of Anatomy and Cell Science, University of Manitoba, Winnipeg, Canada
- Department of Biomedical Engineering, University of Manitoba, Winnipeg, Canada
- Center on Aging, University of Manitoba, Winnipeg, Canada
- Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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16
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Reed RA, Epstein KL, Bramski JH, Diehl KA, Ryan CA. The effect of xylazine on intracranial pressure in anesthetized and standing horses. J Vet Emerg Crit Care (San Antonio) 2021; 31:476-482. [PMID: 34143942 DOI: 10.1111/vec.13083] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/08/2019] [Revised: 02/18/2020] [Accepted: 03/09/2020] [Indexed: 11/28/2022]
Abstract
OBJECTIVE To determine the effect of xylazine on intracranial pressure (ICP) in standing compared to isoflurane-anesthetized horses. DESIGN Prospective, crossover study design. SETTING University Teaching Hospital. ANIMALS Six adult horses donated to the University. Horses were determined to be healthy via physical examination, complete blood count, and neurological evaluation. INTERVENTIONS Horses were anesthetized, maintained on isoflurane in oxygen in left lateral recumbency, and ventilated to normocapnia. Horses were instrumented for intraparenchymal measurement of ICP, invasive blood pressure, pulse oximetry, and end tidal gas analyzer. Xylazine 1 mg/kg was administered IV and ICP, systolic arterial pressure, mean arterial pressure (MAP), diastolic arterial pressure, and heart rate were recorded and cerebral perfusion pressure (CPP) was calculated for the following 15 minutes. Twenty-four to 36 hours following anesthetic recovery, xylazine 1 mg/kg was administered IV and ICP, heart rate, and Doppler blood pressure (BPdop) on the tail were monitored for 15 minutes. MEASUREMENTS AND MAIN RESULTS There was a decrease in ICP following administration of xylazine in anesthetized horses (P < 0.003) but not standing horses (P = 0.227). There was an increase in systolic arterial pressure, MAP, diastolic arterial pressure (P < 0.001), and BPdop (P = 0.001) following administration of xylazine. As a result, CPP increased in anesthetized horses (P < 0.03). There was a negative association between ICP and MAP in anesthetized horses (P = 0.007) but not ICP and BPdop conscious horses (P = 0.379). CONCLUSIONS Administration of xylazine to anesthetized horses resulted in an increased CPP due to decreased ICP with concurrent increased MAP. Administration of xylazine to standing horses did not result in a change in ICP. However, with the increase in BPdop found in awake horses, it is likely that CPP would also increase in awake horses following xylazine administration.
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Affiliation(s)
- Rachel A Reed
- Department of Large Animal Medicine, University of Georgia College of Veterinary Medicine, Athens, Georgia, USA
| | - Kira L Epstein
- Department of Large Animal Medicine, University of Georgia College of Veterinary Medicine, Athens, Georgia, USA
| | - Jessica H Bramski
- Department of Large Animal Medicine, University of Georgia College of Veterinary Medicine, Athens, Georgia, USA
| | - Kathryn A Diehl
- Department of Small Animal Medicine and Surgery, University of Georgia College of Veterinary Medicine, Athens, Georgia, USA
| | - Clare A Ryan
- Department of Large Animal Medicine, University of Georgia College of Veterinary Medicine, Athens, Georgia, USA
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Rakhit S, Nordness MF, Lombardo SR, Cook M, Smith L, Patel MB. Management and Challenges of Severe Traumatic Brain Injury. Semin Respir Crit Care Med 2020; 42:127-144. [PMID: 32916746 DOI: 10.1055/s-0040-1716493] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
Traumatic brain injury (TBI) is the leading cause of death and disability in trauma patients, and can be classified into mild, moderate, and severe by the Glasgow coma scale (GCS). Prehospital, initial emergency department, and subsequent intensive care unit (ICU) management of severe TBI should focus on avoiding secondary brain injury from hypotension and hypoxia, with appropriate reversal of anticoagulation and surgical evacuation of mass lesions as indicated. Utilizing principles based on the Monro-Kellie doctrine and cerebral perfusion pressure (CPP), a surrogate for cerebral blood flow (CBF) should be maintained by optimizing mean arterial pressure (MAP), through fluids and vasopressors, and/or decreasing intracranial pressure (ICP), through bedside maneuvers, sedation, hyperosmolar therapy, cerebrospinal fluid (CSF) drainage, and, in refractory cases, barbiturate coma or decompressive craniectomy (DC). While controversial, direct ICP monitoring, in conjunction with clinical examination and imaging as indicated, should help guide severe TBI therapy, although new modalities, such as brain tissue oxygen (PbtO2) monitoring, show great promise in providing strategies to optimize CBF. Optimization of the acute care of severe TBI should include recognition and treatment of paroxysmal sympathetic hyperactivity (PSH), early seizure prophylaxis, venous thromboembolism (VTE) prophylaxis, and nutrition optimization. Despite this, severe TBI remains a devastating injury and palliative care principles should be applied early. To better affect the challenging long-term outcomes of severe TBI, more and continued high quality research is required.
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Affiliation(s)
- Shayan Rakhit
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Mina F Nordness
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Sarah R Lombardo
- Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee
| | - Madison Cook
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Meharry Medical College, Nashville, Tennessee
| | - Laney Smith
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Washington and Lee University, Lexington, Virginia
| | - Mayur B Patel
- Critical Illness, Brain Dysfunction, and Survivorship Center, Vanderbilt University Medical Center, Nashville, Tennessee.,Division of Trauma, Emergency General Surgery, and Surgical Critical Care, Department of Surgery, Section of Surgical Sciences, Vanderbilt University Medical Center, Nashville, Tennessee.,Department of Neurosurgery and Hearing and Speech Sciences, Vanderbilt Brain Institute, Vanderbilt University Medical Center, Nashville, Tennessee.,Surgical Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee.,Geriatric Research, Education, and Clinical Center Service, Nashville VA Medical Center, Tennessee Valley Healthcare System, US Department of Veterans Affairs, Nashville, Tennessee
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Valadão Cardoso A. An experimental erythrocyte rigidity index (Ri) and its correlations with Transcranial Doppler velocities (TAMMV), Gosling Pulsatility Index PI, hematocrit, hemoglobin concentration and red cell distribution width (RDW). PLoS One 2020; 15:e0229105. [PMID: 32084188 PMCID: PMC7034921 DOI: 10.1371/journal.pone.0229105] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2019] [Accepted: 01/29/2020] [Indexed: 12/17/2022] Open
Abstract
Brain artery velocities (Time-Averaged Maximum Mean Velocity, TAMMV) by Transcranial Doppler (TCD), hematocrit, hemoglobin, Red blood cell (RBC) Distribution Width (RDW) and RBC rigidity index (Ri), when reported together with their correlations, provide a accurate and useful diagnostic picture than blood viscosity measurements alone. Additionally, our study included a sixth parameter provided by TCD, the Gosling Pulsatility Index PI, which is an indicator of CBF (Cerebral Blood Flow) resistance. All these parameters are routine in Hematology except for values of Ri. The rigidity (Ri) of the RBC is the main rheological characteristic of the blood of Sickle Cell Anemia (SCA) patients and several pathologies. However, its quantification depends on many commercial and experimental techniques, none disseminated and predominant around the World. The difference in absorbance values of the blood, during the process of sedimentation in a microwell of a Microplate Reader, is a straightforward way of semi-quantifying the RBC rigidity Ri, since the fraction of irreversibly sickled red blood cells does not form rouleaux. Erythrocyte Rigidity Index (Ri) was calculated using initial absorbance Ainitial (6 s) and final Afinal (540 s), Ri = 1 / (Ai-Af). The Ri of 119 patients (2–17 y / o, M & F) SCA, SCC (Sickle Cell/hemoglobin C), SCD (Sickle Cell/hemoglobin D), Sβ0thal (Sickle Cell/hemoglobin Beta Zero Thalassemia) and 71 blood donors (20–65 y / o, M & F) were measured in our laboratory while the five parameters (TAMMV and PI by TCD, Hct, Hb and RDW) were obtained from medical records. The in vitro addition of hydroxyurea (HU, 50mg /dl, n = 51 patients, and n = 8 healthy donors) in the samples decreased the rouleaux adhesion strength of both donor and patients’ blood samples, leading to extraordinarily high Ri values. The correlation between the studied parameters was especially significant for the direct relationships between Ri, TAMMV, and PI.
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Affiliation(s)
- Antonio Valadão Cardoso
- Rheology Laboratory, Materials Engineering Post-Graduation Program REDEMAT-UEMG/DESP-ED, State University of Minas Gerais, Belo Horizonte, Minas Gerais, Brasil
- * E-mail:
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Lovett ME, Maa T, Moore-Clingenpeel M, O’Brien NF. Transcranial Doppler ultrasound findings in children with moderate-to-severe traumatic brain injury following abusive head trauma. Childs Nerv Syst 2020; 36:993-1000. [PMID: 31781914 PMCID: PMC7224000 DOI: 10.1007/s00381-019-04431-6] [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] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2019] [Accepted: 11/01/2019] [Indexed: 12/26/2022]
Abstract
PURPOSE Abusive head trauma (AHT) is the leading cause of fatal head injuries for children under 2 years. The objective was to evaluate, using transcranial Doppler ultrasound (TCD), whether children with AHT have a similar neurovascular response to injury compared with children without AHT. METHODS Retrospective sub-analysis of previously prospectively acquired data in a pediatric intensive care unit in a level 1 trauma hospital. TCD was performed daily until hospital day 8, discharge, or death. Neurologic outcome was assessed using the Glasgow Outcome Scale Extended (GOS-E Peds) at 1 month from initial injury. RESULTS Sixty-nine children aged 1 day to 17 years with moderate-to-severe traumatic brain injury were enrolled. Fifteen children suffered AHT and 54 had no suspicion for AHT. Fifteen children with AHT underwent 80 serial TCD examinations; 54 children without AHT underwent 308 exams. After standardization for age and gender normative values, there was no statistically significant difference in mean cerebral blood flow velocity of the middle cerebral artery (VMCA) between children with and without AHT. There was no difference in the incidence of extreme cerebral blood flow velocity (CBFV, greater or less than 2 standard deviations from normative value) between groups. Within the AHT group, there were no statistically significant differences in VMCA between children with a favorable (GOS-E Peds 1-4) versus unfavorable neurologic outcome (GOS-E Peds 5-8). CONCLUSION Children with AHT have no significant differences in VMCA or percentage of extreme CBFV in the middle cerebral artery compared to with those without AHT.
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Affiliation(s)
- Marlina E. Lovett
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Tensing Maa
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
| | - Melissa Moore-Clingenpeel
- grid.240344.50000 0004 0392 3476Biostatistics Core, Research Institute at Nationwide Children’s Hospital, Columbus, OH USA
| | - Nicole F. O’Brien
- grid.240344.50000 0004 0392 3476Division of Critical Care Medicine, Nationwide Children’s Hospital, 700 Children’s Dr., Columbus, OH 43205 USA ,grid.261331.40000 0001 2285 7943Department of Pediatrics, The Ohio State University, Columbus, OH USA
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20
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Khan KS, Wiersema UF. Transcranial Doppler waveform changes due to increased cerebrovascular resistance and raised intracranial pressure in a patient with cirrhosis: A difference in shapes, not in numbers. JOURNAL OF CLINICAL ULTRASOUND : JCU 2020; 48:59-63. [PMID: 31774180 DOI: 10.1002/jcu.22799] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/02/2019] [Revised: 10/18/2019] [Accepted: 11/14/2019] [Indexed: 06/10/2023]
Abstract
We report and discuss a case that illustrate the clinical utility of transcranial Doppler (TCD) ultrasound in a patient with cirrhosis. A 43-year-old female presented with acute decompensation of cirrhosis with hepatic encephalopathy, requiring mechanical ventilation. TCD showed low diastolic flow velocities and high pulsatility index (PI) consistent with increased cerebrovascular resistance (CVR). The flow velocities and PI normalized over a period of few days and correlated well with neurological improvement after treatment. Subsequently, the patient developed a large intracerebral hemorrhage with mass effect. The TCD measurements in intracranial hypertension were similar to those with cirrhosis and hepatic encephalopathy. However, the windkessel notch in the systolic phase of TCD waveform, related to the distensibility of arterial wall, was absent during raised intracranial pressure (ICP). The absence of a windkessel notch may help to differentiate a high downstream resistance due to raised ICP from increased CVR.
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Affiliation(s)
- Khurram S Khan
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
| | - Ubbo F Wiersema
- Intensive and Critical Care Unit, Flinders Medical Centre, Bedford Park, South Australia, Australia
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21
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Khan KS. Transcranial Doppler ultrasound in posterior reversible encephalopathy syndrome: A case report. Anaesth Intensive Care 2019; 47:392-396. [PMID: 31423802 DOI: 10.1177/0310057x19869698] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
I describe a case and brief discussion to illustrate the clinical utility of transcranial Doppler ultrasound in suspected posterior reversible encephalopathy syndrome. A 26-year-old female presented with headache, visual disturbance, dyspnoea and hypertension. Past medical history included heart transplantation and hypertension. Cytomegalovirus pneumonia with acute respiratory distress syndrome was diagnosed requiring mechanical ventilation and extracorporeal membrane oxygenation. A brain computed tomographic scan showed changes suggestive of posterior reversible encephalopathy syndrome. Transcranial Doppler showed increased velocities with low pulsatility index consistent with cerebral hyperaemia. After antihypertensive treatment flow velocities and computed tomography normalised with complete clinical recovery.
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Affiliation(s)
- Khurram S Khan
- Intensive and Critical Care Unit, Flinders Medical Centre, Adelaide, Australia
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23
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Noninvasive Measures of Cerebrohemodynamics in Complicated Mild Traumatic Brain Injury. Pediatr Crit Care Med 2019; 20:389-390. [PMID: 30950994 DOI: 10.1097/pcc.0000000000001873] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Fatima N, Shuaib A, Chughtai TS, Ayyad A, Saqqur M. The Role of Transcranial Doppler in Traumatic Brain Injury: A Systemic Review and Meta-Analysis. Asian J Neurosurg 2019; 14:626-633. [PMID: 31497078 PMCID: PMC6702999 DOI: 10.4103/ajns.ajns_42_19] [Citation(s) in RCA: 17] [Impact Index Per Article: 3.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/15/2022] Open
Abstract
To evaluate whether transcranial Doppler (TCD) monitoring plays a role as a prognostic indicator, by being both a diagnostic as well as a monitoring tool for increased intracranial pressure and cerebral vasospasm (VSP), in traumatic brain injury (TBI). Electronic databases and gray literature (unpublished articles) were searched under different MeSH terms from 1990 to the present. Randomized control trials, case–control studies, and prospective cohort studies on TCD in TBI (>18 years old). Clinical outcome measures included Glasgow Coma Outcome Scale (GCOS) and Extended GCOS and mortality. Data were extracted to Review Manager Software. Twenty-five articles that met the inclusion criteria were retrieved and analyzed. Ultimately, five studies were included in our meta-analysis, which revealed that patients with TBI with abnormal TCD (mean flow velocity [MFV] >120 cm/sec or MFV <35 cm/sec and Pulsatility Index >1.2) have a >3-fold higher likelihood of having poor clinical outcome in comparison to patients with TBI and normal TCD monitoring (odds ratio [OR]: 3.87; 95% confidence interval [CI]: 2.97–5.04; P < 0.00001). Subgroup analysis revealed that abnormal TCD has a 9-fold higher likelihood of mortality (OR: 9.96; 95% CI: 4.41–22.47; P < 0.00001). Further, subgroup analysis based on TCD findings revealed that the presence of hypoperfusion on TCD (middle cerebral artery [MCA] <35 cm/s) is associated with a three-fold higher likelihood of having poor functional outcome (OR: 3.72; 95% CI: 1.97–7.0; P < 0.0001). The presence of VSP (MCA >120 cm/s) is associated with three-fold higher likelihood of poor functional outcome (OR: 3.64; 95% CI: 1.55–8.52; P = 0.003). TCD is an evolving diagnostic tool that might play a role in determining the prognosis of patients with TBI. Further prospective study is needed to prove the role of TCD in TBI.
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Affiliation(s)
- Nida Fatima
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | - Ashfaq Shuaib
- Department of Neurology, Hamad General Hospital, Doha, Qatar
| | | | - Ali Ayyad
- Department of Neurosurgery, Hamad General Hospital, Doha, Qatar
| | - Maher Saqqur
- Department of Neurology, Hamad General Hospital, Doha, Qatar
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Feng RY, Chen Q, Yang WJ, Tong XG, Sun ZM, Yan H. Immune Tolerance Therapy: A New Method for Treatment of Traumatic Brain Injury. Chin Med J (Engl) 2018; 131:1990-1998. [PMID: 30082532 PMCID: PMC6085845 DOI: 10.4103/0366-6999.238147] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Objective: Due to the special anatomical structure and pathophysiological mechanism of the central nervous system (CNS), there is a big difference between the repair of brain injury and other systems of the body. More and more evidence shows that targetedly reducing the autoimmune response of brain tissue without affecting the immune function in other parts of the body will be the best optimized treatment for brain injury. Data Sources: This review was based on data in articles published in PubMed up to June 5, 2017, with the following keywords: “immune tolerance”, “traumatic brain injury”, and “central nervous system”. Study Selection: Original articles and critical reviews on immune tolerance and brain damage were selected for this review. References of the retrieved articles were also screened to search for potentially relevant papers. Results: The CNS is isolated from the immune system through the blood-brain barrier. After brain injury, brain antigens are released into the systemic circulation to induce damaging immune responses. Immune tolerance can effectively reduce the brain edema and neurological inflammatory response after brain injury, which is beneficial to the recovery of neurological function. The clinical application prospect and theoretical research value of the treatment of immune tolerance on traumatic brain injury (TBI) is worth attention. Conclusions: The establishment of immune tolerance mechanism has a high clinical value in the treatment of TBI. It opens up new opportunities for the treatment of brain damage.
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Affiliation(s)
- Ruo-Yang Feng
- Department of Neurosurgery, Tianjin Medical University, Tianjin 300070, China
| | - Qian Chen
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases; Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Wei-Jian Yang
- Department of Neurosurgery, Tianjin Medical University, Tianjin 300070, China
| | - Xiao-Guang Tong
- Department of Neurosurgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Zhi-Ming Sun
- Department of Spine Surgery, Tianjin Huanhu Hospital, Tianjin 300350, China
| | - Hua Yan
- Tianjin Key Laboratory of Cerebral Vascular and Neurodegenerative Diseases, Tianjin 300350, China
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Deines JJ, Chang J, Reuter-Rice K. Cerebral Blood Flow Velocities and Functional Outcomes in Pediatric Mild Traumatic Brain Injury. J Neurotrauma 2018; 36:135-141. [PMID: 30044180 PMCID: PMC6306683 DOI: 10.1089/neu.2017.5577] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Outcomes can be challenging to predict in children with mild traumatic brain injury (TBI). Transcranial Doppler (TCD) ultrasound has become an increasingly useful modality in adult and pediatric TBI by measuring blood flow velocities within the circle of Willis. In children with moderate-to-severe TBI, multiple studies have correlated abnormal TCD measurements and poor outcomes. Additionally, TCD has shown value in assessing adults with mild brain injury. To date, there are no studies that correlate TCD findings and outcomes in children with mild TBI. We hypothesize that altered cerebral blood flow after mild TBI is associated with poor functional outcome using the Glasgow Outcome Scale-Extended, Pediatrics (GOS-E Peds). TCD was performed within 24 h of admission on 60 patients at a tertiary Level 1 children's hospital. A secondary analysis was performed on the subgroup of 28 mild TBI patients. GOS-E Peds was measured at the time of hospital discharge and 4-6 weeks post-discharge. Cerebral blood flow velocities did not show correlation with outcome. At discharge, the right-sided Spearman's correlation coefficient was 0.19 (p value = 0.33) and the left-sided was 0.36 (p = 0.06). At follow up the right-sided coefficient was -0.04 (p = 0.84), the left-sided was -0.25 (p = 0.24). Pulsatility index likewise showed no correlation. Right and left-sided correlation at discharge were -0.25 (p = 0.19) and 0.01 (p = 0.96), respectively. At follow up the right side showed 0.004 (p = 0.99), and the left showed 0.18 (p = 0.41). Although our data did not show correlation, it showed that the investigation could feasibly be done in pediatric patients with mild TBI. The study was limited by small sample size and infrequent outcome of interest. Future studies may help define the role of TCD in the large population of mild pediatric TBI patients.
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Affiliation(s)
- Jake J. Deines
- Department of Pediatrics, Golisano Children's Hospital/University of Rochester, Rochester, New York
| | - Jianhong Chang
- Duke University School of Nursing, Durham, North Carolina
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Peckham ME, Anderson JS, Rassner UA, Shah LM, Hinckley PJ, de Havenon A, Kim SE, McNally JS. Low b-value diffusion weighted imaging is promising in the diagnosis of brain death and hypoxic-ischemic injury secondary to cardiopulmonary arrest. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2018; 22:165. [PMID: 29925413 PMCID: PMC6011248 DOI: 10.1186/s13054-018-2087-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2018] [Accepted: 05/30/2018] [Indexed: 12/20/2022]
Abstract
Background Cardiorespiratory arrest can result in a spectrum of hypoxic ischemic brain injury leading to global hypoperfusion and brain death (BD). Because up to 40% of patients with BD are viable organ donors, avoiding delayed diagnosis of this condition is critical. High b-value diffusion weighted imaging (DWI) measures primarily molecular self-diffusion; however, low b-values are sensitive to perfusion. We investigated the feasibility of low b-value DWI in discriminating the global hypoperfusion of BD and hypoxic ischemic encephalopathy (HIE). Methods We retrospectively reviewed cardiorespiratory arrest subjects with a diagnosis of HIE or BD. Inclusion criteria included brain DWI acquired at both low (50 s/mm2) and high (1000–2000 s/mm2) b-values. Automated segmentation was used to determine mean b50 apparent diffusion coefficient (ADC) values in gray and white matter regions. Normal subjects with DWI at both values were used as age- and sex-matched controls. Results We evaluated 64 patients (45 with cardiorespiratory arrest and 19 normal). Cardiorespiratory arrest patients with BD had markedly lower mean b50 ADC in gray matter regions compared with HIE (0.70 ± 0.18 vs. 1.95 ± 0.25 × 10−3 mm2/s, p < 0.001) and normal subjects (vs. 1.79 ± 0.12 × 10−3 mm2/s, p < 0.001). HIE had higher mean b50 ADC compared with normal (1.95 ± 0.25 vs. 1.79 ± 0.12 × 10−3 mm2/s, p = 0.016). There was wide separation of gray matter ADC values in BD subjects compared with age matched normal and HIE subjects. White matter values were also markedly decreased in the BD population, although they were less predictive than gray matter. Conclusion Low b-value DWI is promising for the discrimination of HIE with maintained perfusion and brain death in cardiorespiratory arrest.
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Affiliation(s)
- Miriam E Peckham
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA. .,Department of Radiology and Imaging Sciences, University of Utah Health Sciences Center, 30 North, 1900 East #1A071, Salt Lake City, UT, 84132-2140, USA.
| | - Jeffrey S Anderson
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Ulrich A Rassner
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Lubdha M Shah
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Peter J Hinckley
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
| | - Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Seong-Eun Kim
- Utah Center for Advanced Imaging Research, Department of Radiology, University of Utah, Salt Lake City, UT, USA
| | - J Scott McNally
- Department of Radiology and Imaging Sciences, University of Utah, Salt Lake City, UT, USA
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Li L, Chopp M, Ding G, Li Q, Mahmood A, Jiang Q. Chronic global analysis of vascular permeability and cerebral blood flow after bone marrow stromal cell treatment of traumatic brain injury in the rat: A long-term MRI study. Brain Res 2017; 1675:61-70. [PMID: 28899758 DOI: 10.1016/j.brainres.2017.09.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/06/2017] [Revised: 08/29/2017] [Accepted: 09/04/2017] [Indexed: 12/11/2022]
Abstract
Vascular permeability and hemodynamic alteration in response to the transplantation of human bone marrow stromal cells (hMSCs) after traumatic brain injury (TBI) were longitudinally investigated in non directly injured and normal-appearing cerebral tissue using magnetic resonance imaging (MRI). Male Wistar rats (300-350g, n=30) subjected to controlled cortical impact TBI were intravenously injected with 1ml of saline (at 6-h or 1-week post-injury, n=5/group) or with hMSCs in suspension (∼3×106 hMSCs, at 6-h or 1-week post-injury, n=10/group). MRI measurements of T2-weighted imaging, cerebral blood flow (CBF) and blood-to-brain transfer constant (Ki) of gadolinium-diethylenetriamine pentaacetic acid (Gd-DTPA), and neurological behavioral estimates were performed on all animals at multiple time points up to 3-months post-injury. Our long-term imaging data show that blood-brain barrier (BBB) breakdown and hemodynamic disruption after TBI, as revealed by Ki and CBF, respectively, affect both hemispheres of the brain in a diffuse manner. Our data reveal a sensitive vascular permeability and hemodynamic reaction in response to the time-dependent transplantation of hMSCs. A more rapid reduction of Ki following cell treatment is associated with a higher level of CBF in the injured brain, and acute (6h) cell administration leads to enhanced therapeutic effects on both the recovery of vascular integrity and stabilization of cerebral perfusion compared to delayed (1w) cell engraftment. Our results indicate that cell-enhanced BBB reconstitution plays an important role in underlying the restoration of CBF in the injured brain, which in turn, contributes to the improvement of functional outcome.
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Affiliation(s)
- Lian Li
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Michael Chopp
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA; Department of Physics, Oakland University, Rochester, MI 48309, USA.
| | - Guangliang Ding
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Qingjiang Li
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA.
| | - Asim Mahmood
- Department of Neurosurgery, Henry Ford Health System, Detroit, MI 48208, USA.
| | - Quan Jiang
- Department of Neurology, Henry Ford Health System, Detroit, MI 48202, USA.
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Robba C, Cardim D, Sekhon M, Budohoski K, Czosnyka M. Transcranial Doppler: a stethoscope for the brain-neurocritical care use. J Neurosci Res 2017; 96:720-730. [PMID: 28880397 DOI: 10.1002/jnr.24148] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/12/2017] [Accepted: 08/10/2017] [Indexed: 02/03/2023]
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive bedside monitoring technique that can evaluate cerebral blood flow hemodynamics in the intracranial arterial vasculature. TCD allows assessment of linear cerebral blood flow velocity, with a high temporal resolution and is inexpensive, reproducible, and portable. The aim of this review is to provide an overview of the most commonly used TCD derived signals and measurements used commonly in neurocritical care. We describe both basic (flow velocity, pulsatility index) and advanced concepts, including critical closing pressure, wall tension, autoregulation, noninvasive intracranial pressure, brain compliance, and cerebrovascular time constant; we also describe the clinical applications of TCD to highlight their utility in the diagnosis and monitoring of cerebrovascular diseases as the "stethoscope for the brain."
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Affiliation(s)
- Chiara Robba
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University, Box 1, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ.,Division of Neuroscience, University of Genoa, Genoa, Italy
| | - Danilo Cardim
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia
| | - Karol Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Riberholt CG, Olesen ND, Thing M, Juhl CB, Mehlsen J, Petersen TH. Impaired Cerebral Autoregulation during Head Up Tilt in Patients with Severe Brain Injury. PLoS One 2016; 11:e0154831. [PMID: 27168188 PMCID: PMC4864314 DOI: 10.1371/journal.pone.0154831] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2016] [Accepted: 04/19/2016] [Indexed: 12/12/2022] Open
Abstract
Early mobilization is of importance for improving long-term outcome for patients after severe acquired brain injury. A limiting factor for early mobilization by head-up tilt is orthostatic intolerance. The purpose of the present study was to examine cerebral autoregulation in patients with severe acquired brain injury and a low level of consciousness. Fourteen patients with severe acquired brain injury and orthostatic intolerance and fifteen healthy volunteers were enrolled. Blood pressure was evaluated by pulse contour analysis, heart rate and RR-intervals were determined by electrocardiography, middle cerebral artery velocity was evaluated by transcranial Doppler, and near-infrared spectroscopy determined frontal lobe oxygenation in the supine position and during head-up tilt. Cerebral autoregulation was evaluated as the mean flow index calculated as the ratio between middle cerebral artery mean velocity and estimated cerebral perfusion pressure. Patients with acquired brain injury presented an increase in mean flow index during head-up tilt indicating impaired autoregulation (P < 0.001). Spectral analysis of heart rate variability in the frequency domain revealed lower magnitudes of ~0.1 Hz spectral power in patients compared to healthy controls suggesting baroreflex dysfunction. In conclusion, patients with severe acquired brain injury and orthostatic intolerance during head-up tilt have impaired cerebral autoregulation more than one month after brain injury.
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Affiliation(s)
- Christian Gunge Riberholt
- Research Unit on Brain Injury Neuro Rehabilitation Copenhagen, Department of Neurorehabilitation/ TBI Unit, Rigshospitalet, Copenhagen, Denmark
| | - Niels Damkjær Olesen
- Department of Anaesthesia, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroscience and Pharmacology, University of Copenhagen, Copenhagen, Denmark
| | - Mira Thing
- Department of Paediatrics, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
| | - Carsten Bogh Juhl
- Research Unit for Musculoskeletal Function and Physiotherapy, Department of Sports Science and Clinical Biomechanics, University of Southern Denmark, Odense, Denmark
- Department of Rehabilitation, Copenhagen University Hospital Herlev and Gentofte, Gentofte, Denmark
| | - Jesper Mehlsen
- Coordinating Research Centre, Bispebjerg & Frederiksberg Hospital, Frederiksberg, Denmark
| | - Tue Hvass Petersen
- Research Unit on Brain Injury Neuro Rehabilitation Copenhagen, Department of Neurorehabilitation/ TBI Unit, Rigshospitalet, Copenhagen, Denmark
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