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Mirsajadi A, Erickson D, Alias S, Froese L, Singh Sainbhi A, Gomez A, Majumdar R, Herath I, Wilson M, Zarychanski R, Zeiler FA, Mendelson AA. Microvascular Autoregulation in Skeletal Muscle Using Near-Infrared Spectroscopy and Derivation of Optimal Mean Arterial Pressure in the ICU: Pilot Study and Comparison With Cerebral Near-Infrared Spectroscopy. Crit Care Explor 2024; 6:e1111. [PMID: 38904977 PMCID: PMC11196085 DOI: 10.1097/cce.0000000000001111] [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] [Indexed: 06/22/2024] Open
Abstract
IMPORTANCE Microvascular autoregulation (MA) maintains adequate tissue perfusion over a range of arterial blood pressure (ABP) and is frequently impaired in critical illness. MA has been studied in the brain to derive personalized hemodynamic targets after brain injury. The ability to measure MA in other organs is not known, which may inform individualized management during shock. OBJECTIVES This study determines the feasibility of measuring MA in skeletal muscle using near-infrared spectroscopy (NIRS) as a marker of tissue perfusion, the derivation of optimal mean arterial pressure (MAPopt), and comparison with indices from the brain. DESIGN Prospective observational study. SETTING Medical and surgical ICU in a tertiary academic hospital. PARTICIPANTS Adult critically ill patients requiring vasoactive support on the first day of ICU admission. MAIN OUTCOMES AND MEASURES Fifteen critically ill patients were enrolled. NIRS was applied simultaneously to skeletal muscle (brachioradialis) and brain (frontal cortex) while ABP was measured continuously via invasive catheter. MA correlation indices were calculated between ABP and NIRS from skeletal muscle total hemoglobin (MVx), muscle tissue saturation index (MOx), brain total hemoglobin (THx), and brain tissue saturation index (COx). Curve fitting algorithms derive the MAP with the lowest correlation index value, which is the MAPopt. RESULTS MAPopt values were successfully calculated for each correlation index for all patients and were frequently (77%) above 65 mm Hg. For all correlation indices, median time was substantially above impaired MA threshold (24.5-34.9%) and below target MAPopt (9.0-78.6%). Muscle and brain MAPopt show moderate correlation (MVx-THx r = 0.76, p < 0.001; MOx-COx r = 0.69, p = 0.005), with a median difference of -1.27 mm Hg (-9.85 to -0.18 mm Hg) and 0.05 mm Hg (-7.05 to 2.68 mm Hg). CONCLUSIONS AND RELEVANCE This study demonstrates, for the first time, the feasibility of calculating MA indices and MAPopt in skeletal muscle using NIRS. Future studies should explore the association between impaired skeletal muscle MA, ICU outcomes, and organ-specific differences in MA and MAPopt thresholds.
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Affiliation(s)
- Amirali Mirsajadi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Dustin Erickson
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Soumya Alias
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Logan Froese
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Amanjyot Singh Sainbhi
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Division of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada
| | - Raju Majumdar
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Isuru Herath
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Maggie Wilson
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Ryan Zarychanski
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Medical Oncology and Hematology, University of Manitoba/CancerCare Manitoba, Winnipeg, MB, Canada
| | - Frederick A. Zeiler
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Neurosurgery, Department of Surgery, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, MB, Canada
- Pan Am Clinic Foundation, Winnipeg, MB, Canada
| | - Asher A. Mendelson
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Critical Care Medicine, Department of Medicine, University of Manitoba, Winnipeg, MB, Canada
- Department of Physiology, University of Manitoba, Winnipeg, MB, Canada
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Plante V, Basu M, Gettings JV, Luchette M, LaRovere KL. Update in Pediatric Neurocritical Care: What a Neurologist Caring for Critically Ill Children Needs to Know. Semin Neurol 2024; 44:362-388. [PMID: 38788765 DOI: 10.1055/s-0044-1787047] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/26/2024]
Abstract
Currently nearly one-quarter of admissions to pediatric intensive care units (PICUs) worldwide are for neurocritical care diagnoses that are associated with significant morbidity and mortality. Pediatric neurocritical care is a rapidly evolving field with unique challenges due to not only age-related responses to primary neurologic insults and their treatments but also the rarity of pediatric neurocritical care conditions at any given institution. The structure of pediatric neurocritical care services therefore is most commonly a collaborative model where critical care medicine physicians coordinate care and are supported by a multidisciplinary team of pediatric subspecialists, including neurologists. While pediatric neurocritical care lies at the intersection between critical care and the neurosciences, this narrative review focuses on the most common clinical scenarios encountered by pediatric neurologists as consultants in the PICU and synthesizes the recent evidence, best practices, and ongoing research in these cases. We provide an in-depth review of (1) the evaluation and management of abnormal movements (seizures/status epilepticus and status dystonicus); (2) acute weakness and paralysis (focusing on pediatric stroke and select pediatric neuroimmune conditions); (3) neuromonitoring modalities using a pathophysiology-driven approach; (4) neuroprotective strategies for which there is evidence (e.g., pediatric severe traumatic brain injury, post-cardiac arrest care, and ischemic stroke and hemorrhagic stroke); and (5) best practices for neuroprognostication in pediatric traumatic brain injury, cardiac arrest, and disorders of consciousness, with highlights of the 2023 updates on Brain Death/Death by Neurological Criteria. Our review of the current state of pediatric neurocritical care from the viewpoint of what a pediatric neurologist in the PICU needs to know is intended to improve knowledge for providers at the bedside with the goal of better patient care and outcomes.
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Affiliation(s)
- Virginie Plante
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Meera Basu
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
| | | | - Matthew Luchette
- Division of Critical Care Medicine, Department of Anesthesiology, Perioperative and Pain Medicine, Boston Children's Hospital, Boston, Massachusetts
| | - Kerri L LaRovere
- Department of Neurology, Boston Children's Hospital, Boston, Massachusetts
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Stein KY, Froese L, Sekhon M, Griesdale D, Thelin EP, Raj R, Tas J, Aries M, Gallagher C, Bernard F, Gomez A, Kramer AH, Zeiler FA. Intracranial Pressure-Derived Cerebrovascular Reactivity Indices and Their Critical Thresholds: A Canadian High Resolution-Traumatic Brain Injury Validation Study. J Neurotrauma 2024; 41:910-923. [PMID: 37861325 DOI: 10.1089/neu.2023.0374] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2023] Open
Abstract
Current neurointensive care guidelines recommend intracranial pressure (ICP) and cerebral perfusion pressure (CPP) centered management for moderate-severe traumatic brain injury (TBI) because of their demonstrated associations with patient outcome. Cerebrovascular reactivity metrics, such as the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC index, have also demonstrated significant prognostic capabilities with regard to outcome. However, critical thresholds for cerebrovascular reactivity indices have only been identified in two studies conducted at the same center. In this study, we aim to determine the critical thresholds of these metrics by leveraging a unique multi-center database. The study included a total of 354 patients from the CAnadian High-Resolution TBI (CAHR-TBI) Research Collaborative. Based on 6-month Glasgow Outcome Scores, patients were dichotomized into alive versus dead and favorable versus unfavorable. Chi-square values were then computed for incrementally increasing values of each physiological parameter of interest against outcome. The values that generated the greatest chi-squares for each parameter were considered to be the thresholds with the greatest outcome discriminatory capacity. To confirm that the identified thresholds provide prognostic utility, univariate and multivariable logistical regression analyses were performed adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. Through the chi-square analysis, a lower limit CPP threshold of 60 mm Hg and ICP thresholds of 18 mm Hg and 22 mm Hg were identified for both survival and favorable outcome predictions. For the cerebrovascular reactivity metrics, different thresholds were identified for the two outcome dichotomizations. For survival prediction, thresholds of 0.35, 0.25, and 0 were identified for PRx, PAx, and RAC, respectively. For favorable outcome prediction, thresholds of 0.325, 0.20, and 0.05 were found. Univariate logistical regression analysis demonstrated that the time spent above/below thresholds were associated with outcome. Further, multivariable logistical regression analysis found that percent time above/below the identified thresholds added additional variance to the IMPACT core model for predicting both survival and favorable outcome. In this study, we were able to validate the results of the previous two works as well as to reaffirm the ICP and CPP guidelines from the Brain Trauma Foundation (BTF) and the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC).
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mypinder Sekhon
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andreas H Kramer
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Risinger Liljegren A, Brorsson C, Karlsson M, Koskinen LOD, Sundström N. Cerebrovascular Pressure Reactivity Measures: Index Comparison and Clinical Outcome in Patients With Traumatic Brain Injury Treated According to an Intracranial Pressure-Focused Management: Rejection of the Null Hypothesis. Neurotrauma Rep 2023; 4:848-856. [PMID: 38156075 PMCID: PMC10754344 DOI: 10.1089/neur.2023.0074] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2023] Open
Abstract
The aim was to investigate whether the pressure reactivity indices PRx, long-PRx (L-PRx), and pressure reactivity (PR) are interchangeable as measures of vascular reactivity, and whether they correlate with clinical outcome when an intracranial pressure (ICP)-targeted treatment regimen is applied in patients with traumatic brain injury (TBI). Patients with TBI (n = 29) that arrived at the hospital within 24 h of injury were included. PRx and L-PRx were derived from Pearson correlations between mean arterial pressure (MAP) and ICP over a short- and long-time interval. PR was the regression coefficient between the hourly mean values of ICP and MAP. Indices were compared to each other, parameters at admission, and outcome assessed by the extended Glasgow Outcome Scale-Extended (GOSE) at 6 and 12 months. PRx and L-PRx had the strongest correlation with each other (R = 0.536, p < 0.01). A correlation was also noted between L-PRx and PR (R = 0.475, p < 0.01), but not between PRx and PR. A correlation was found between age and PRx (R = 0.482, p = 0.01). No association with outcome for any of the indices was found. PRx/L-PRx and L-PRx/PR were moderately correlated with each other. Age was associated with PRx. None of the indices correlated with outcome when our ICP treatment regime was applied. Part of our null hypothesis, that the three indices are associated with outcome, must be rejected. There was, however, an association between some of the indices. To further understand the relation of treatment regimes and pressure reactivity indices, a larger, randomized study is warranted.
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Affiliation(s)
- Axel Risinger Liljegren
- Department of Clinical Science-Neurosciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Camilla Brorsson
- Department of Surgery and Perioperative Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Marcus Karlsson
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Lars-Owe D. Koskinen
- Department of Clinical Science-Neurosciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
| | - Nina Sundström
- Department of Radiation Sciences, Radiation Physics, Biomedical Engineering, Umeå University, Umeå, Sweden
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Sarwal A, Robba C, Venegas C, Ziai W, Czosnyka M, Sharma D. Are We Ready for Clinical Therapy based on Cerebral Autoregulation? A Pro-con Debate. Neurocrit Care 2023; 39:269-283. [PMID: 37165296 DOI: 10.1007/s12028-023-01741-1] [Citation(s) in RCA: 9] [Impact Index Per Article: 9.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2022] [Accepted: 04/19/2023] [Indexed: 05/12/2023]
Abstract
Cerebral autoregulation (CA) is a physiological mechanism that maintains constant cerebral blood flow regardless of changes in cerebral perfusion pressure and prevents brain damage caused by hypoperfusion or hyperperfusion. In recent decades, researchers have investigated the range of systemic blood pressures and clinical management strategies over which cerebral vasculature modifies intracranial hemodynamics to maintain cerebral perfusion. However, proposed clinical interventions to optimize autoregulation status have not demonstrated clear clinical benefit. As future trials are designed, it is crucial to comprehend the underlying cause of our inability to produce robust clinical evidence supporting the concept of CA-targeted management. This article examines the technological advances in monitoring techniques and the accuracy of continuous assessment of autoregulation techniques used in intraoperative and intensive care settings today. It also examines how increasing knowledge of CA from recent clinical trials contributes to a greater understanding of secondary brain injury in many disease processes, despite the fact that the lack of robust evidence influencing outcomes has prevented the translation of CA-guided algorithms into clinical practice.
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Affiliation(s)
- Aarti Sarwal
- Atrium Wake Forest School of Medicine, Winston-Salem, NC, USA.
| | | | - Carla Venegas
- Mayo Clinic School of Medicine, Jacksonville, FL, USA
| | - Wendy Ziai
- Johns Hopkins University School of Medicine and Johns Hopkins Bayview Medical Center, Baltimore, MD, USA
| | - Marek Czosnyka
- Division of Neurosurgery, Cambridge University Hospital, Cambridge, UK
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Gritti P, Bonfanti M, Zangari R, Farina A, Longhi L, Rasulo FA, Bertuetti R, Biroli A, Biroli F, Lorini FL. Evaluation and Application of Ultra-Low-Resolution Pressure Reactivity Index in Moderate or Severe Traumatic Brain Injury. J Neurosurg Anesthesiol 2023; 35:313-321. [PMID: 35499152 DOI: 10.1097/ana.0000000000000847] [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] [Received: 10/13/2021] [Accepted: 03/24/2022] [Indexed: 11/26/2022]
Abstract
BACKGROUND The pressure reactivity index (PRx) has emerged as a surrogate method for the continuous bedside estimation of cerebral autoregulation and a predictor of unfavorable outcome after traumatic brain injury (TBI). However, calculation of PRx require continuous high-resolution monitoring currently limited to specialized intensive care units. The aim of this study was to evaluate a new index, the ultra-low-frequency PRx (UL-PRx) sampled at ∼0.0033 Hz at ∼5 minutes periods, and to investigate its association with outcome. METHODS Demographic data, admission Glasgow coma scale, in-hospital mortality and Glasgow outcome scale extended at 12 months were extracted from electronic records. The filtering and preparation of time series of intracranial pressure (ICP), mean arterial pressure and cerebral perfusion pressure (CPP), and calculation of the indices (UL-PRx, Δ-optimal CPP), were performed in MATLAB using an in-house algorithm. RESULTS A total of 164 TBI patients were included in the study; in-hospital and 12-month mortality was 29.3% and 38.4%, respectively, and 64% of patients had poor neurological outcome at 12 months. On univariate analysis, ICP, CPP, UL-PRx, and ΔCPPopt were associated with 12-month mortality. After adjusting for age, Glasgow coma scale, ICP and CPP, mean UL-PRx and UL-PRx thresholds of 0 and +0.25 remained associated with 12-month mortality. Similar findings were obtained for in-hospital mortality. For mean UL-PRx, the area under the receiver operating characteristic curves for in-hospital and 12-month mortality were 0.78 (95% confidence interval [CI]: 0.69-0.87; P <0.001) and 0.70 (95% CI: 0.61-0.79; P <0.001), respectively, and 0.65 (95% CI: 0.57-0.74; P =0.001) for 12-month neurological outcome. CONCLUSIONS Our findings indicate that ultra-low-frequency sampling might provide sufficient resolution to derive information about the state of cerebrovascular autoregulation and prediction of 12-month outcome in TBI patients.
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Affiliation(s)
- Paolo Gritti
- Department of Anesthesia and Critical Care Medicine
| | | | - Rosalia Zangari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo
| | | | - Luca Longhi
- Department of Anesthesia and Critical Care Medicine
| | - Frank A Rasulo
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Bertuetti
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Antonio Biroli
- Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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Kastenholz N, Megjhani M, Conzen-Dilger C, Albanna W, Veldeman M, Nametz D, Kwon SB, Schulze-Steinen H, Ridwan H, Clusmann H, Schubert GA, Park S, Weiss M. The oxygen reactivity index indicates disturbed local perfusion regulation after aneurysmal subarachnoid hemorrhage: an observational cohort study. Crit Care 2023; 27:235. [PMID: 37312192 PMCID: PMC10265851 DOI: 10.1186/s13054-023-04452-3] [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: 03/10/2023] [Accepted: 04/19/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Cerebral autoregulation (CA) can be impaired in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The Pressure Reactivity Index (PRx, correlation of blood pressure and intracranial pressure) and Oxygen Reactivity Index (ORx, correlation of cerebral perfusion pressure and brain tissue oxygenation, PbtO2) are both believed to estimate CA. We hypothesized that CA could be poorer in hypoperfused territories during DCI and that ORx and PRx may not be equally effective in detecting such local variances. METHODS ORx and PRx were compared daily in 76 patients with aSAH with or without DCI until the time of DCI diagnosis. The ICP/PbtO2-probes of DCI patients were retrospectively stratified by being in or outside areas of hypoperfusion via CT perfusion image, resulting in three groups: DCI + /probe + (DCI patients, probe located inside the hypoperfused area), DCI + /probe- (probe outside the hypoperfused area), DCI- (no DCI). RESULTS PRx and ORx were not correlated (r = - 0.01, p = 0.56). Mean ORx but not PRx was highest when the probe was located in a hypoperfused area (ORx DCI + /probe + 0.28 ± 0.13 vs. DCI + /probe- 0.18 ± 0.15, p < 0.05; PRx DCI + /probe + 0.12 ± 0.17 vs. DCI + /probe- 0.06 ± 0.20, p = 0.35). PRx detected poorer autoregulation during the early phase with relatively higher ICP (days 1-3 after hemorrhage) but did not differentiate the three groups on the following days when ICP was lower on average. ORx was higher in the DCI + /probe + group than in the other two groups from day 3 onward. ORx and PRx did not differ between patients with DCI, whose probe was located elsewhere, and patients without DCI (ORx DCI + /probe- 0.18 ± 0.15 vs. DCI- 0.20 ± 0.14; p = 0.50; PRx DCI + /probe- 0.06 ± 0.20 vs. DCI- 0.08 ± 0.17, p = 0.35). CONCLUSIONS PRx and ORx are not interchangeable measures of autoregulation, as they likely measure different homeostatic mechanisms. PRx represents the classical cerebrovascular reactivity and might be better suited to detect disturbed autoregulation during phases with moderately elevated ICP. Autoregulation may be poorer in territories affected by DCI. These local perfusion disturbances leading up to DCI may be more readily detected by ORx than PRx. Further research should investigate their robustness to detect DCI and to serve as a basis for autoregulation-targeted treatment after aSAH.
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Affiliation(s)
- Nick Kastenholz
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Murad Megjhani
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Daniel Nametz
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Soon Bin Kwon
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Henna Schulze-Steinen
- Department of Intensive Care Medicine and Perioperative Care, RWTH Aachen University, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Soojin Park
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
- Department of Biomedical Informatics, Columbia University, New York City, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
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Giardina A, Cardim D, Ciliberti P, Battaglini D, Ball L, Kasprowicz M, Beqiri E, Smielewski P, Czosnyka M, Frisvold S, Groznik M, Pelosi P, Robba C. Effects of positive end-expiratory pressure on cerebral hemodynamics in acute brain injury patients. Front Physiol 2023; 14:1139658. [PMID: 37200838 PMCID: PMC10185889 DOI: 10.3389/fphys.2023.1139658] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Background: Cerebral autoregulation is the mechanism that allows to maintain the stability of cerebral blood flow despite changes in cerebral perfusion pressure. Maneuvers which increase intrathoracic pressure, such as the application of positive end-expiratory pressure (PEEP), have been always challenged in brain injured patients for the risk of increasing intracranial pressure (ICP) and altering autoregulation. The primary aim of this study is to assess the effect of PEEP increase (from 5 to 15 cmH2O) on cerebral autoregulation. Secondary aims include the effect of PEEP increase on ICP and cerebral oxygenation. Material and Methods: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP monitoring and undergoing multimodal neuromonitoring including ICP, cerebral perfusion pressure (CPP) and cerebral oxygenation parameters obtained with near-infrared spectroscopy (NIRS), and an index which expresses cerebral autoregulation (PRx). Additionally, values of arterial blood gases were analyzed at PEEP of 5 and 15 cmH2O. Results are expressed as median (interquartile range). Results: Twenty-five patients were included in this study. The median age was 65 years (46-73). PEEP increase from 5 to 15 cmH2O did not lead to worsened autoregulation (PRx, from 0.17 (-0.003-0.28) to 0.18 (0.01-0.24), p = 0.83). Although ICP and CPP changed significantly (ICP: 11.11 (6.73-15.63) to 13.43 (6.8-16.87) mm Hg, p = 0.003, and CPP: 72.94 (59.19-84) to 66.22 (58.91-78.41) mm Hg, p = 0.004), these parameters did not reach clinically relevant levels. No significant changes in relevant cerebral oxygenation parameters were observed. Conclusion: Slow and gradual increases of PEEP did not alter cerebral autoregulation, ICP, CPP and cerebral oxygenation to levels triggering clinical interventions in acute brain injury patients.
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Affiliation(s)
- Alberto Giardina
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Pietro Ciliberti
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | | | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Shirin Frisvold
- Anesthesia and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
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10
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Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [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: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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11
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Dias C, de Castro A, Gaio R, Silva R, Pereira E, Monteiro E. Lung Injury Risk in Traumatic Brain Injury Managed With Optimal Cerebral Perfusion Pressure Guided-Therapy. J Crit Care Med (Targu Mures) 2023; 9:97-105. [PMID: 37593249 PMCID: PMC10429626 DOI: 10.2478/jccm-2023-0009] [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: 08/11/2022] [Accepted: 01/31/2023] [Indexed: 08/19/2023] Open
Abstract
Introduction Management of traumatic brain injury (TBI) has to counterbalance prevention of secondary brain injury without systemic complications, namely lung injury. The potential risk of developing acute respiratory distress syndrome (ARDS) leads to therapeutic decisions such as fluid balance restriction, high PEEP and other lung protective measures, that may conflict with neurologic outcome. In fact, low cerebral perfusion pressure (CPP) may induce secondary ischemic injury and mortality, but disproportionate high CPP may also increase morbidity and worse lung compliance and hypoxia with the risk of developing ARDS and fatal outcome. The evaluation of cerebral autoregulation at bedside and individualized (optimal CPP) CPPopt-guided therapy, may not only be a relevant measure to protect the brain, but also a safe measure to avoid systemic complications. Aim of the study We aimed to study the safety of CPPopt-guided-therapy and the risk of secondary lung injury association with bad outcome. Methods and results Single-center retrospective analysis of 92 severe TBI patients admitted to the Neurocritical Care Unit managed with CPPopt-guided-therapy by PRx (pressure reactivity index). During the first 10 days, we collected data from blood gas, ventilation and brain variables. Evolution along time was analyzed using linear mixed-effects regression models. 86% were male with mean age 53±21 years. 49% presented multiple trauma and 21% thoracic trauma. At hospital admission, median GCS was 7 and after 3-months GOS was 3. Monitoring data was CPP 86±7mmHg, CPP-CPPopt -2.8±10.2mmHg and PRx 0.03±0.19. The average PFratio (PaO2/FiO2) was 305±88 and driving pressure 15.9±3.5cmH2O. PFratio exhibited a significant quadratic dependence across time and PRx and driving pressure presented significant negative association with PFRatio. CPP and CPPopt did not present significant effect on PFratio (p=0.533; p=0.556). A significant positive association between outcome and the difference CPP-CPPopt was found. Conclusion Management of TBI using CPPopt-guided-therapy was associated with better outcome and seems to be safe regarding the development of secondary lung injury.
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Affiliation(s)
- Celeste Dias
- Faculty of Medicine, University of Porto, Porto, Portugal
- University Hospital Centre São João, PortoPortugal
| | | | - Rita Gaio
- Faculty of Mathematics, University of Porto, Porto, Portugal
- Centre of Mathematics of the University of Porto, Porto, Portugal
| | - Ricardo Silva
- Faculty of Mathematics, University of Porto, Porto, Portugal
| | | | - Elisabete Monteiro
- Faculty of Medicine, University of Porto, Porto, Portugal
- University Hospital Centre São João, PortoPortugal
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12
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Gritti P, Bonfanti M, Zangari R, Bonanomi E, Pellicioli I, Mandelli P, Longhi L, Rasulo FA, Bertuetti R, Farina A, Biroli F, Lorini FL. Evaluation and application of ultra-low-frequency pressure reactivity index in pediatric traumatic brain injury patients. Acta Neurochir (Wien) 2023; 165:865-874. [PMID: 36847979 DOI: 10.1007/s00701-023-05538-1] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/25/2022] [Accepted: 02/18/2023] [Indexed: 03/01/2023]
Abstract
PURPOSE While clinical practice suggests that knowing the cerebral autoregulation (CA) status of traumatic brain injury (TBI) patients is crucial in assessing the best treatment, evidence in pediatric TBI (pTBI) is limited. The pressure reactivity index (PRx) is a surrogate method for the continuous estimation of CA in adults; however, calculations require continuous, high-resolution monitoring data. We evaluate an ultra-low-frequency pressure reactivity index (UL-PRx), based on data sampled at ∼5-min periods, and test its association with 6-month mortality and unfavorable outcome in a cohort of pTBI patients. METHODS Data derived from pTBI patients (0-18 years) requiring intracranial pressure (ICP) monitoring were retrospectively collected and processed in MATLAB using an in-house algorithm. RESULTS Data on 47 pTBI patients were included. UL-PRx mean values, ICP, cerebral perfusion pressure (CPP), and derived indices showed significant association with 6-month mortality and unfavorable outcome. A value of UL-PRx of 0.30 was identified as the threshold to better discriminate both surviving vs deceased patients (AUC: 0.90), and favorable vs unfavorable outcomes (AUC: 0.70) at 6 months. At multivariate analysis, mean UL-PRx and % time with ICP > 20 mmHg, remained significantly associated with 6-month mortality and unfavorable outcome, even when adjusted for International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-Core variables. In six patients undergoing secondary decompressive craniectomy, no significant changes in UL-PRx were found after surgery. CONCLUSIONS UL-PRx is associated with a 6-month outcome even if adjusted for IMPACT-Core. Its application in pediatric intensive care unit could be useful to evaluate CA and offer possible prognostic and therapeutic implications in pTBI patients. CLINICALTRIALS GOV: NCT05043545, September 14, 2021, retrospectively registered.
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Affiliation(s)
- Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy.
| | - Marco Bonfanti
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Isabella Pellicioli
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Pietro Mandelli
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Luca Longhi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Frank A Rasulo
- Anesthesiology, Intensive Care and Emergency Medicine, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Rita Bertuetti
- Anesthesiology, Intensive Care and Emergency Medicine, Department of Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Alessia Farina
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Francesco Biroli
- FROM Research Foundation, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Ferdinando Luca Lorini
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
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13
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Gomez A, Sekhon M, Griesdale D, Froese L, Yang E, Thelin EP, Raj R, Aries M, Gallagher C, Bernard F, Kramer AH, Zeiler FA. Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study. Intensive Care Med Exp 2022; 10:54. [PMID: 36550386 PMCID: PMC9780411 DOI: 10.1186/s40635-022-00482-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Brain tissue oxygen tension (PbtO2) and cerebrovascular pressure reactivity monitoring have emerged as potential modalities to individualize care in moderate and severe traumatic brain injury (TBI). The relationship between these modalities has had limited exploration. The aim of this study was to examine the relationship between PbtO2 and cerebral perfusion pressure (CPP) and how this relationship is modified by the state of cerebrovascular pressure reactivity. METHODS A retrospective multi-institution cohort study utilizing prospectively collected high-resolution physiologic data from the CAnadian High Resolution-TBI (CAHR-TBI) Research Collaborative database collected between 2011 and 2021 was performed. Included in the study were critically ill TBI patients with intracranial pressure (ICP), arterial blood pressure (ABP), and PbtO2 monitoring treated in any one of three CAHR-TBI affiliated adult intensive care units (ICU). The outcome of interest was how PbtO2 and CPP are related over a cohort of TBI patients and how this relationship is modified by the state of cerebrovascular reactivity, as determined using the pressure reactivity index (PRx). RESULTS A total of 77 patients met the study inclusion criteria with a total of 377,744 min of physiologic data available for the analysis. PbtO2 produced a triphasic curve when plotted against CPP like previous population-based plots of cerebral blood flow (CBF) versus CPP. The triphasic curve included a plateau region flanked by regions of relative ischemia (hypoxia) and hyperemia (hyperoxia). The plateau region shortened when cerebrovascular pressure reactivity was disrupted compared to when it was intact. CONCLUSIONS In this exploratory analysis of a multi-institution high-resolution physiology TBI database, PbtO2 seems to have a triphasic relationship with CPP, over the entire cohort. The CPP range over which the plateau exists is modified by the state of cerebrovascular reactivity. This indicates that in critically ill TBI patients admitted to ICU, PbtO2 may be reflective of CBF.
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Affiliation(s)
- Alwyn Gomez
- grid.21613.370000 0004 1936 9609Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ,grid.21613.370000 0004 1936 9609Present Address: Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Mypinder Sekhon
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Present Address: Division of Critical Care, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Donald Griesdale
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada
| | - Logan Froese
- grid.21613.370000 0004 1936 9609Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB Canada
| | - Eleen Yang
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada
| | - Eric P. Thelin
- grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- grid.7737.40000 0004 0410 2071Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marcel Aries
- grid.412966.e0000 0004 0480 1382Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- grid.22072.350000 0004 1936 7697Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Francis Bernard
- grid.14848.310000 0001 2292 3357Section of Critical Care, Department of Medicine, University of Montreal, Montreal, QC Canada
| | - Andreas H. Kramer
- grid.22072.350000 0004 1936 7697Department of Critical Care Medicine, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Frederick A. Zeiler
- grid.21613.370000 0004 1936 9609Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ,grid.21613.370000 0004 1936 9609Present Address: Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada ,grid.21613.370000 0004 1936 9609Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB Canada ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.21613.370000 0004 1936 9609Centre On Aging, University of Manitoba, Winnipeg, Canada ,grid.5335.00000000121885934Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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14
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El-Swaify ST, Kamel M, Ali SH, Bahaa B, Refaat MA, Amir A, Abdelrazek A, Beshay PW, Basha AKMM. Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges. Surg Neurol Int 2022; 13:431. [DOI: 10.25259/sni_609_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).
Methods:
We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.
Results:
This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.
Conclusion:
Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.
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Affiliation(s)
- Seif Tarek El-Swaify
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Menna Kamel
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Ali
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassem Bahaa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman Amir
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Pavly Wagih Beshay
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
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15
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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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16
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Evaluation and Application of Ultra-Low-Resolution Pressure Reactivity Index in Moderate or Severe Traumatic Brain Injury. J Neurosurg Anesthesiol 2022. [DOI: 10.1097/ana.0000000000000847 10.1097/ana.0000000000000847] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/01/2023]
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17
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Casault C, Couillard P, Kromm J, Rosenthal E, Kramer A, Brindley P. Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners. J Intensive Care Soc 2022; 23:191-202. [PMID: 35615230 PMCID: PMC9125434 DOI: 10.1177/1751143720980273] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Traumatic brain injury (TBI) is common and potentially devastating. Traditional examination-based patient monitoring following TBI may be inadequate for frontline clinicians to reduce secondary brain injury through individualized therapy. Multimodal neurologic monitoring (MMM) offers great potential for detecting early injury and improving outcomes. By assessing cerebral oxygenation, autoregulation and metabolism, clinicians may be able to understand neurophysiology during acute brain injury, and offer therapies better suited to each patient and each stage of injury. Hence, we offer this primer on brain tissue oxygen monitoring, pressure reactivity index monitoring and cerebral microdialysis. This narrative review serves as an introductory guide to the latest clinically-relevant evidence regarding key neuromonitoring techniques.
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Affiliation(s)
- Colin Casault
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
| | - Philippe Couillard
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Julie Kromm
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Eric Rosenthal
- Department of Critical Care
Medicine, University of Alberta, Edmonton, Canada
| | - Andreas Kramer
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Peter Brindley
- Department of Neurology, Harvard
University, Boston, MA, USA
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18
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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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19
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Cruz Navarro J, Ponce Mejia LL, Robertson C. A Precision Medicine Agenda in Traumatic Brain Injury. Front Pharmacol 2022; 13:713100. [PMID: 35370671 PMCID: PMC8966615 DOI: 10.3389/fphar.2022.713100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury remains a leading cause of death and disability across the globe. Substantial uncertainty in outcome prediction continues to be the rule notwithstanding the existing prediction models. Additionally, despite very promising preclinical data, randomized clinical trials (RCTs) of neuroprotective strategies in moderate and severe TBI have failed to demonstrate significant treatment effects. Better predictive models are needed, as the existing validated ones are more useful in prognosticating poor outcome and do not include biomarkers, genomics, proteonomics, metabolomics, etc. Invasive neuromonitoring long believed to be a "game changer" in the care of TBI patients have shown mixed results, and the level of evidence to support its widespread use remains insufficient. This is due in part to the extremely heterogenous nature of the disease regarding its etiology, pathology and severity. Currently, the diagnosis of traumatic brain injury (TBI) in the acute setting is centered on neurological examination and neuroimaging tools such as CT scanning and MRI, and its treatment has been largely confronted using a "one-size-fits-all" approach, that has left us with many unanswered questions. Precision medicine is an innovative approach for TBI treatment that considers individual variability in genes, environment, and lifestyle and has expanded across the medical fields. In this article, we briefly explore the field of precision medicine in TBI including biomarkers for therapeutic decision-making, multimodal neuromonitoring, and genomics.
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Affiliation(s)
- Jovany Cruz Navarro
- Departments of Anesthesiology and Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Lucido L Ponce Mejia
- Departments of Neurosurgery and Neurology, LSU Health Science Center, New Orleans, LA, United States
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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20
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Batson C, Stein KY, Gomez A, Sainbhi AS, Froese L, Alizadeh A, Mathieu F, Zeiler FA. Intracranial Pressure–Derived Cerebrovascular Reactivity Indices, Chronological Age, and Biological Sex in Traumatic Brain Injury: A Scoping Review. Neurotrauma Rep 2022; 3:44-56. [PMID: 35112107 PMCID: PMC8804238 DOI: 10.1089/neur.2021.0054] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/29/2023] Open
Abstract
To date, there has been limited literature exploring the association between age and sex with cerebrovascular reactivity (CVR) in moderate/severe traumatic brain injury (TBI). Given the known link between age, sex, and cerebrovascular function, knowledge of the impacts on continuously assessed CVR is critical for the development of future therapeutics. We conducted a scoping review of the literature for studies that had a direct statistical interrogation of the relationship between age, sex, and continuous intracranial pressure (ICP)-based indices of CVR in moderate/severe TBI. The ICP-based indices researched included: pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC. MEDLINE, BIOSIS, EMBASE, SCOPUS, Global Health, and the Cochrane library were searched from inception to June 2021 for relevant articles. A total of 10 original studies fulfilled our inclusion criteria. Nine of the articles documented a correlation between advanced age and worse CVR, with eight using PRx (2192 total patients), three using PAx (978 total patients), and one using RAC (358 total patients), p < 0.05; R ranging from 0.17 to 0.495 for all indices across all studies. Three articles (1256 total patients) displayed a correlation between biological sex and PRx, with females trending towards higher PRx values (p < 0.05) in the limited available literature. However, no literature exists comparing PAx or RAC with biological sex. Findings showed that aging was associated with impaired CVR. We observed a trend between female sex and worse PRx values, but the literature was limited and statistical significance was borderline. The identified studies were few in number, carried significant population heterogeneity, and utilized grand averaging of large epochs of physiology during statistical comparisons with age and biological sex. Because of the heterogeneous nature of TBI populations and limited focus on the effects of age and sex on outcomes in TBI, it is challenging to highlight the differences between the indices and patient age groups and sex. The largest study showing an association between PRx and age was done by Zeiler and colleagues, where 165 patients were studied noting that patients with a mean PRx value above zero had a mean age above 51.4 years versus a mean age of 41.4 years for those with a mean PRx value below zero (p = 0.0007). The largest study showing an association between PRx and sex was done by Czosnyka and colleagues, where 469 patients were studied noting that for patients <50 years of age, PRx was worse in females (0.11 ± 0.047) compared to males (0.044 ± 0.031), p < 0.05. The findings from these 10 studies provide preliminary data, but are insufficient to definitively characterize the impact of age and sex on CVR in moderate/severe TBI. Future work in the field should focus on the impact of age and sex on multi-modal cerebral physiological monitoring.
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Affiliation(s)
- Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Kevin Y. Stein
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Arsalan Alizadeh
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Francois Mathieu
- Interdepartmental Division of Critical Care, Department of Medicine, University of Toronto, Toronto, Ontario, Canada
| | - Frederick A. Zeiler
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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21
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Zeiler FA, Iturria-Medina Y, Thelin EP, Gomez A, Shankar JJ, Ko JH, Figley CR, Wright GEB, Anderson CM. Integrative Neuroinformatics for Precision Prognostication and Personalized Therapeutics in Moderate and Severe Traumatic Brain Injury. Front Neurol 2021; 12:729184. [PMID: 34557154 PMCID: PMC8452858 DOI: 10.3389/fneur.2021.729184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023] Open
Abstract
Despite changes in guideline-based management of moderate/severe traumatic brain injury (TBI) over the preceding decades, little impact on mortality and morbidity have been seen. This argues against the “one-treatment fits all” approach to such management strategies. With this, some preliminary advances in the area of personalized medicine in TBI care have displayed promising results. However, to continue transitioning toward individually-tailored care, we require integration of complex “-omics” data sets. The past few decades have seen dramatic increases in the volume of complex multi-modal data in moderate and severe TBI care. Such data includes serial high-fidelity multi-modal characterization of the cerebral physiome, serum/cerebrospinal fluid proteomics, admission genetic profiles, and serial advanced neuroimaging modalities. Integrating these complex and serially obtained data sets, with patient baseline demographics, treatment information and clinical outcomes over time, can be a daunting task for the treating clinician. Within this review, we highlight the current status of such multi-modal omics data sets in moderate/severe TBI, current limitations to the utilization of such data, and a potential path forward through employing integrative neuroinformatic approaches, which are applied in other neuropathologies. Such advances are positioned to facilitate the transition to precision prognostication and inform a top-down approach to the development of personalized therapeutics in moderate/severe TBI.
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Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.,Centre on Aging, University of Manitoba, Winnipeg, MB, Canada.,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Yasser Iturria-Medina
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada.,McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, QC, Canada.,Ludmer Centre for Neuroinformatics and Mental Health, Montreal, QC, Canada
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jai J Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ji Hyun Ko
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Chase R Figley
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.,Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Galen E B Wright
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chris M Anderson
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada.,Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
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22
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Lilja-Cyron A, Zeiler FA, Beqiri E, Cabeleira M, Smielewski P, Czosnyka M. Optimal Cerebral Perfusion Pressure Based on Intracranial Pressure-Derived Indices of Cerebrovascular Reactivity: Which One Is Better for Outcome Prediction in Moderate/Severe Traumatic Brain Injury? ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:173-179. [PMID: 33839841 DOI: 10.1007/978-3-030-59436-7_35] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 03/07/2023]
Abstract
Intracranial pressure (ICP)-derived indices of cerebrovascular reactivity (e.g., PRx, PAx, and RAC) have been developed to improve understanding of brain status from available neuromonitoring variables. These indices are moving correlation coefficients between slow-wave vasogenic fluctuations in ICP and arterial blood pressure. In this retrospective analysis of neuromonitoring data from 200 patients admitted with moderate/severe traumatic brain injury (TBI), we evaluate the predictive value of CPPopt based on these ICP-derived indices of cerebrovascular reactivity. Valid CPPopt values were obtained in 92.3% (PRx), 86.7% (PAX), and 84.6% (RAC) of the monitoring periods, respectively. In multivariate logistic analysis, a baseline model that includes age, sex, and admission Glasgow Coma Score had an area under the receiver operating curve of 0.762 (P < 0.0001) for dichotomous outcome prediction (dead vs. good recovery). When adding time/dose of CPP below CPPopt, all multivariate models (based on PRx, PAx, and RAC) predicted the dichotomous outcome measure, but additional value of the prediction was only significantly added by the PRx-based calculations of time spent with CPP below CPPopt and dose of CPP below CPPopt.
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Affiliation(s)
- Alexander Lilja-Cyron
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK. .,Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark.
| | - Frederick A Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Rady Faculty of Health Sciences, Department of Surgery, University of Manitoba, Winnipeg, Canada.,Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Department of Pathophysiology and Transplantation, University of Milan, Milano, Italy
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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23
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Iaccarino C, Lippa L, Munari M, Castioni CA, Robba C, Caricato A, Pompucci A, Signoretti S, Zona G, Rasulo FA. Management of intracranial hypertension following traumatic brain injury: a best clinical practice adoption proposal for intracranial pressure monitoring and decompressive craniectomy. Joint statements by the Traumatic Brain Injury Section of the Italian Society of Neurosurgery (SINch) and the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). J Neurosurg Sci 2021; 65:219-238. [PMID: 34184860 DOI: 10.23736/s0390-5616.21.05383-2] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
No robust evidence is provided by literature regarding the management of intracranial hypertension following severe traumatic brain injury (TBI). This is mostly due to the lack of prospective randomized controlled trials (RCTs), the presence of studies containing extreme heterogeneously collected populations and controversial considerations about chosen outcome. A scientific society should provide guidelines for care management and scientific support for those areas for which evidence-based medicine has not been identified. However, RCTs in severe TBI have failed to establish intervention effectiveness, arising the need to make greater use of tools such as Consensus Conferences between experts, which have the advantage of providing recommendations based on experience, on the analysis of updated literature data and on the direct comparison of different logistic realities. The Italian scientific societies should provide guidelines following the national laws ruling the best medical practice. However, many limitations do not allow the collection of data supporting high levels of evidence for intracranial pressure (ICP) monitoring and decompressive craniectomy (DC) in patients with severe TBI. This intersociety document proposes best practice guidelines for this subsetting of patients to be adopted on a national Italian level, along with joint statements from "TBI Section" of the Italian Society of Neurosurgery (SINch) endorsed by the Neuroanesthesia and Neurocritical Care Study Group of the Italian Society of Anesthesia, Analgesia, Resuscitation and Intensive Care (SIAARTI). Presented here is a recap of recommendations on management of ICP and DC supported a high level of available evidence and rate of agreement expressed by the assemblies during the more recent consensus conferences, where members of both groups have had a role of active participants and supporters. The listed recommendations have been sent to a panel of experts consisting of the 107 members of the "TBI Section" of the SINch and the 111 members of the Neuroanesthesia and Neurocritical Care Study Group of the SIAARTI. The aim of the survey was to test a preliminary evaluation of the grade of predictable future adherence of the recommendations following this intersociety proposal. The following recommendations are suggested as representing best clinical practice, nevertheless, adoption of local multidisciplinary protocols regarding thresholds of ICP values, drug therapies, hemostasis management and perioperative care of decompressed patients is strongly recommended to improve treatment efficiency, to increase the quality of data collection and to provide more powerful evidence with future studies. Thus, for this future perspective a rapid overview of the role of the multimodal neuromonitoring in the optimal severe TBI management is also provided in this document. It is reasonable to assume that the recommendations reported in this paper will in future be updated by new observations arising from future trials. They are not binding, and this document should be offered as a guidance for clinical practice through an intersociety agreement, taking in consideration the low level of evidence.
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Affiliation(s)
- Corrado Iaccarino
- Division of Neurosurgery, Department of Biomedical, Metabolic and Neural Sciences, University of Modena and Reggio Emilia, Modena University Hospital, Modena, Italy
| | - Laura Lippa
- Department of Neurosurgery, Ospedali Riuniti di Livorno, Livorno, Italy -
| | - Marina Munari
- Department of Anesthesia and Intensive Care, Padua University Hospital, Padua, Italy
| | - Carlo A Castioni
- Department of Anesthesia and Intensive Care, IRCCS Istituto delle Scienze Neurologiche Bellaria Hospital, Bologna, Italy
| | - Chiara Robba
- Department of Anesthesia and Intensive Care, IRCCS San Martino University Hospital, Genoa, Italy
| | - Anselmo Caricato
- Department of Anesthesia and Critical Care, IRCCS A. Gemelli University Polyclinic Foundation, Rome, Italy
| | - Angelo Pompucci
- Department of Neurosurgery, S. Maria Goretti Hospital, Latina, Italy
| | - Stefano Signoretti
- Division of Emergency-Urgency, Unit of Neurosurgery, S. Eugenio Hospital, Rome, Italy
| | - Gianluigi Zona
- Department of Neurosurgery, IRCCS San Martino University Hospital, Genoa, Italy.,Department of Neuroscience, Rehabilitation, Ophthalmology, Genetics and Maternal and Child Health (DINOGMI), University of Genoa, Genoa, Italy
| | - Frank A Rasulo
- Department of Anesthesiology, Intensive Care and Emergency Medicine, Spedali Civili University Hospital, Brescia, Italy.,Department of Surgical and Medical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
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24
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Scarboro M, McQuillan KA. Traumatic Brain Injury Update. AACN Adv Crit Care 2021; 32:29-50. [PMID: 33725106 DOI: 10.4037/aacnacc2021331] [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: 11/01/2022]
Abstract
Traumatic brain injury is a devastating, life-changing event in most cases. After the primary brain insult, it is helpful to use evidence-based monitoring techniques to guide implementation of essential interventions to minimize secondary injury and thereby improve patient outcomes. An update on multimodal neuromonitoring is provided in this narrative review, with discussion of tools and techniques currently used in the treatment of patients with brain injury. Neuroprotective treatments, from the well-studied targeted temperature management to new potential therapeutics under investigation, such as glyburide, also are presented.
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Affiliation(s)
- Maureen Scarboro
- Maureen Scarboro is Acute Care Nurse Practitioner, Neurosurgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Karen A McQuillan
- Karen A. McQuillan is Lead Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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25
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Zeiler FA. Advanced Bio-signal Analytics for Continuous Bedside Monitoring of Aneurysmal Subarachnoid Hemorrhage: The Future. Neurocrit Care 2021; 34:375-378. [PMID: 33403580 DOI: 10.1007/s12028-020-01170-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/18/2020] [Accepted: 11/24/2020] [Indexed: 10/22/2022]
Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada. .,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada. .,Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada. .,Centre on Aging, University of Manitoba, Winnipeg, Canada. .,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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26
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Zeiler FA, Mathieu F, Monteiro M, Glocker B, Ercole A, Cabeleira M, Stocchetti N, Smielewski P, Czosnyka M, Newcombe V, Menon DK. Systemic Markers of Injury and Injury Response Are Not Associated with Impaired Cerebrovascular Reactivity in Adult Traumatic Brain Injury: A Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) Study. J Neurotrauma 2020; 38:870-878. [PMID: 33096953 DOI: 10.1089/neu.2020.7304] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022] Open
Abstract
The role of extra-cranial injury burden and systemic injury response on cerebrovascular response in traumatic brain injury (TBI) is poorly documented. This study preliminarily assesses the association between admission features of extra-cranial injury burden on cerebrovascular reactivity. Using the Collaborative European Neurotrauma Effectiveness Research in TBI High-Resolution ICU (HR ICU) sub-study cohort, we evaluated those patients with both archived high-frequency digital intra-parenchymal intra-cranial pressure monitoring data of a minimum of 6 h in duration, and the presence of a digital copy of their admission computed tomography (CT) scan. Digital physiologic signals were processed for pressure reactivity index (PRx) and both the percent time above defined PRx thresholds and mean hourly dose above threshold. This was conducted for both the first 72 h and entire duration of recording. Admission extra-cranial injury characteristics and CT injury scores were obtained from the database, with quantitative contusion, edema, intraventricular hemorrhage, and extra-axial lesion volumes were obtained via semi-automated segmentation. Comparison between admission extra-cranial markers of injury and PRx metrics was conducted using Mann-Whitney U testing, and logistic regression techniques, adjusting for known CT injury metrics associated with impaired PRx. A total of 165 patients were included. Evaluating the entire ICU recording period, there was limited association between metrics of extra-cranial injury burden and impaired cerebrovascular reactivity. Using the first 72 h of recording, admission temperature (p = 0.042) and white blood cell % (WBC %; p = 0.013) were statistically associated with impaired cerebrovascular reactivity on Mann-Whitney U and univariate logistic regression. After adjustment for admission age, pupillary status, GCS motor score, pre-hospital hypoxia/hypotension, and intra-cranial CT characteristics associated with impaired reactivity, temperature (p = 0.021) and WBC % (p = 0.013) remained significantly associated with mean PRx values above +0.25 and +0.35, respectively. Markers of extra-cranial injury burden and systemic injury response do not appear to be strongly associated with impaired cerebrovascular reactivity in TBI during both the initial and entire ICU stay.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada.,Center on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - François Mathieu
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ari Ercole
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia Newcombe
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- Division of Anesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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27
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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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28
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Trans-ocular brain impedance index for assessment of cerebral autoregulation in a porcine model of cerebral hemodynamic perturbation. J Clin Monit Comput 2020; 35:1007-1014. [PMID: 32666400 DOI: 10.1007/s10877-020-00556-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/07/2020] [Accepted: 07/07/2020] [Indexed: 12/11/2022]
Abstract
Cerebrovascular autoregulation (CA) is often impaired following traumatic brain injury. Established technologies and metrics used to assess CA are invasive and conducive for measurement, but not for continuous monitoring. We developed a trans-ocular brain impedance (TOBI) method that may provide non-invasive and continuous indices to assess CA. In this study, we monitored impedance metrics such as respiratory-induced impedance amplitude changes (dz) as well as a novel impedance index (DZx), which is a moving Pearson correlation between mean arterial pressure (MAP) and dz. Yorkshire swine were instrumented to continuously record ICP, MAP, and cerebral blood flow (CBF). TOBI was recorded by placement of standard ECG electrodes on closed eyelids and connected to a data acquisition system. MAP, ICP and CBF were manipulated utilizing an intravenous vasopressor challenge. TOBI indices (dz and DZx) were compared to the hemodynamic indicators as well as pressure reactivity index (PRx). During the vasopressor challenge, dz was highly correlated with ICP, CPP, and CBF (r = < - 0.49, p < 0.0001). ICP, CPP, and CBF had a mean percent increase (standard deviation) from baseline of 29(23.2)%, 70(25)%, and 37(72.6)% respectively while dz decreased by 31(15.6)%. Receiver operator curve test showed high predictive performance of DZx when compared to PRx with area under the curve above 0.86, with high sensitivity and specificity. Impedance indices appear to track changes in PRx and hemodynamics that affect cerebral autoregulation. TOBI may be a suitable less invasive surrogate to PRx and capable of tracking cerebral autoregulation.
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Unnerbäck M, Ottesen JT, Reinstrup P. Increased Intracranial Pressure Attenuates the Pulsating Component of Cerebral Venous Outflow. Neurocrit Care 2020; 31:273-279. [PMID: 31240621 PMCID: PMC6757136 DOI: 10.1007/s12028-019-00733-4] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Background The underlying physiology of the intracranial pressure (ICP) curve morphology is still poorly understood. If this physiology is explained it could be possible to extract clinically relevant information from the ICP curve. The venous outflow from the cranial cavity is pulsatile, and in theory the pulsatile component of venous outflow from the cranial cavity should be attenuated with increasing ICP. In this study, we explored the relationship between ICP and the pulsatility of the venous outflow from the intracranial cavity. Methods Thirty-seven neuro-intensive care patients that had been examined with phase-contrast magnetic resonance imaging regarding cerebral blood flow (CBF) through the internal carotid and vertebral arteries and venous flow in the internal jugular veins were retrospectively included. The pulsatility of the jugular flow was determined by calculating the venous pulsatile index. The results were correlated to clinical data registered in the patient data monitoring system, including ICP and cerebral perfusion pressure (CPP). Results CBF was 996 ± 298 ml/min, and the flow in the internal jugular veins equaled 67 ± 17% of the CBF, with a range of 22–97%. The venous pulsatile index correlated negatively to ICP (R = − 0.47 p = 0.003). The lowest flow in the internal jugular veins over the cardiac cycle (Fmin) was not correlated to ICP. Temperature, end-tidal CO2, MAP, and CPP were not correlated to venous pulsatility. Conclusion An increase in ICP correlates to a lower pulsatility of the venous outflow from the cranial cavity. A lower pulsatility could be due to increased pressure requirements to compress intracranial veins with increasing ICP.
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Affiliation(s)
- Mårten Unnerbäck
- Department of Clinical Sciences Lund, Intensive Care and Perioperative Medicine, Lund University, Skåne University Hospital, Malmö, Sweden. .,IPV SUS Malmö, Inga Marie Nilssons gata 47, 205 02, Malmö, Sweden.
| | - Johnny T Ottesen
- Department of Science and Environment, Roskilde University, Roskilde, Denmark
| | - Peter Reinstrup
- Department of Clinical Sciences Lund, Department of Neurosurgery, Lund University, Skåne University Hospital, Lund, Sweden
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Froese L, Batson C, Gomez A, Dian J, Zeiler FA. The Limited Impact of Current Therapeutic Interventions on Cerebrovascular Reactivity in Traumatic Brain Injury: A Narrative Overview. Neurocrit Care 2020; 34:325-335. [PMID: 32468328 DOI: 10.1007/s12028-020-01003-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Current intensive care unit (ICU) treatment strategies for traumatic brain injury (TBI) care focus on intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-directed therapeutics, dictated by guidelines. Impaired cerebrovascular reactivity in moderate/severe TBI is emerging as a major associate with poor outcome and appears to dominate the landscape of physiologic derangement over the course of a patient's ICU stay. Within this article, we review the literature on the known drivers of impaired cerebrovascular reactivity in adult TBI, highlight the current knowledge surrounding the impact of guideline treatment strategies on continuously monitored cerebrovascular reactivity, and discuss current treatment paradigms for impaired reactivity. Finally, we touch on the areas of future research, as we strive to develop specific therapeutics for impaired cerebrovascular reactivity in TBI. There exists limited literature to suggest advanced age, intracranial injury patterns of diffuse injury, and sustained ICP elevations may drive impaired cerebrovascular reactivity. To date, the literature suggests there is a limited impact of such ICP/CPP guideline-based therapies on cerebrovascular reactivity, with large portions of a given patients ICU period spent with impaired cerebrovascular reactivity. Emerging treatment paradigms focus on the targeting individualized CPP and ICP thresholds based on cerebrovascular reactivity, without directly targeting the pathways involved in its dysfunction. Further work involved in uncovering the molecular pathways involved in impaired cerebrovascular reactivity is required, so that we can develop therapeutics directed at its prevention and treatment.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Josh Dian
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Centre on Aging, University of Manitoba, Winnipeg, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Zeiler FA, Mathieu F, Monteiro M, Glocker B, Ercole A, Beqiri E, Cabeleira M, Stocchetti N, Smielewski P, Czosnyka M, Newcombe V, Menon DK. Diffuse Intracranial Injury Patterns Are Associated with Impaired Cerebrovascular Reactivity in Adult Traumatic Brain Injury: A CENTER-TBI Validation Study. J Neurotrauma 2020; 37:1597-1608. [PMID: 32164482 DOI: 10.1089/neu.2019.6959] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Recent single-center retrospective analysis displayed the association between admission computed tomography (CT) markers of diffuse intracranial injury and worse cerebrovascular reactivity. The goal of this study was to further explore these associations using the prospective multi-center Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high-resolution intensive care unit (HR ICU) data set. Using the CENTER-TBI HR ICU sub-study cohort, we evaluated those patients with both archived high-frequency digital physiology (100 Hz or higher) and the presence of a digital admission CT scan. Physiological signals were processed for pressure reactivity index (PRx) and both the percent (%) time above defined PRx thresholds and mean hourly dose above threshold. Admission CT injury scores were obtained from the database. Quantitative contusion, edema, intraventricular hemorrhage (IVH), and extra-axial lesion volumes were obtained via semi-automated segmentation. Comparison between admission CT characteristics and PRx metrics was conducted using Mann-U, Jonckheere-Terpstra testing, with a combination of univariate linear and logistic regression techniques. A total of 165 patients were included. Cisternal compression and high admission Rotterdam and Helsinki CT scores, and Marshall CT diffuse injury sub-scores were associated with increased percent (%) time and hourly dose above PRx threshold of 0, +0.25, and +0.35 (p < 0.02 for all). Logistic regression analysis displayed an association between deep peri-contusional edema and mean PRx above a threshold of +0.25. These results suggest that diffuse injury patterns, consistent with acceleration/deceleration forces, are associated with impaired cerebrovascular reactivity. Diffuse admission intracranial injury patterns appear to be consistently associated with impaired cerebrovascular reactivity, as measured through PRx. This is in keeping with the previous single-center retrospective literature on the topic. This study provides multi-center validation for those results, and provides preliminary data to support potential risk stratification for impaired cerebrovascular reactivity based on injury pattern.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Biomedical Engineering, Faculty of Engineering, and University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - François Mathieu
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Division of Neurosurgery, Department of Surgery, University of Toronto, Toronto, Ontario, Canada
| | - Miguel Monteiro
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ben Glocker
- Biomedical Image Analysis Group, Imperial College London, London, United Kingdom
| | - Ari Ercole
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Virginia Newcombe
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- Division of Anesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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32
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Zeiler FA, Ercole A, Czosnyka M, Smielewski P, Hawryluk G, Hutchinson PJA, Menon DK, Aries M. Continuous cerebrovascular reactivity monitoring in moderate/severe traumatic brain injury: a narrative review of advances in neurocritical care. Br J Anaesth 2020; 124:440-453. [PMID: 31983411 DOI: 10.1016/j.bja.2019.11.031] [Citation(s) in RCA: 35] [Impact Index Per Article: 8.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2019] [Revised: 11/19/2019] [Accepted: 11/21/2019] [Indexed: 12/18/2022] Open
Abstract
Impaired cerebrovascular reactivity in adult moderate and severe traumatic brain injury (TBI) is known to be associated with worse global outcome at 6-12 months. As technology has improved over the past decades, monitoring of cerebrovascular reactivity has shifted from intermittent measures, to experimentally validated continuously updating indices at the bedside. Such advances have led to the exploration of individualised physiologic targets in adult TBI management, such as optimal cerebral perfusion pressure (CPP) values, or CPP limits in which vascular reactivity is relatively intact. These targets have been shown to have a stronger association with outcome compared with existing consensus-based guideline thresholds in severe TBI care. This has sparked ongoing prospective trials of such personalised medicine approaches in adult TBI. In this narrative review paper, we focus on the concept of cerebral autoregulation, proposed mechanisms of control and methods of continuous monitoring used in TBI. We highlight multimodal cranial monitoring approaches for continuous cerebrovascular reactivity assessment, physiologic and neuroimaging correlates, and associations with outcome. Finally, we explore the recent 'state-of-the-art' advances in personalised physiologic targets based on continuous cerebrovascular reactivity monitoring, their benefits, and implications for future avenues of research in TBI.
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Affiliation(s)
- Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada; Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK; Biomedical Engineering, Faculty of Engineering, Winnipeg, Canada; Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Section of Brain Physics, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK; Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Section of Brain Physics, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Gregory Hawryluk
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, Winnipeg, Canada
| | - Peter J A Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, the Netherlands
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33
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Bajpai BK, Zakelis R, Deimantavicius M, Imbrasiene D. Comparative Study of Novel Noninvasive Cerebral Autoregulation Volumetric Reactivity Indices Reflected by Ultrasonic Speed and Attenuation as Dynamic Measurements in the Human Brain. Brain Sci 2020; 10:brainsci10040205. [PMID: 32244750 PMCID: PMC7226251 DOI: 10.3390/brainsci10040205] [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: 03/03/2020] [Revised: 03/22/2020] [Accepted: 03/26/2020] [Indexed: 11/20/2022] Open
Abstract
This is a comparative study of two novel noninvasive cerebrovascular autoregulation (CA) monitoring methods based on intracranial blood volume (IBV) changes in the human brain. We investigated the clinical applicability of the new volumetric reactivity index (VRx2), reflected by intracranial ultrasonic attenuation dynamics for noninvasive CA monitoring. The CA was determined noninvasively on 43 healthy participants by calculating the volumetric reactivity index (VRx1 from time-of-flight of ultrasound, VRx2 from attenuation of ultrasound). The VRx was calculated as a moving correlation coefficient between the arterial blood pressure and noninvasively measured IBV slow waves. Linear regression between VRx1 and VRx2 (averaged per participants) showed a significant correlation (r = 0.731, p < 0.0001, 95% confidence interval [0.501–0.895]) in data filtered by bandpass filtering. On the other hand, FIR filtering demonstrated a slightly better correlation (r = 0.769, p < 0.0001, 95% confidence interval [0.611–0.909]). The standard deviation of the difference by bandpass filtering was 0.1647 and bias −0.3444; and by FIR filtering 0.1382 and bias −0.3669. This comparative study showed a significant coincidence of the VRx2 index compared to that of VRx1. Hence, VRx2 could be used as an alternative, cost-effective noninvasive cerebrovascular autoregulation index in the same way as VRx1 values are used.
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Affiliation(s)
- Basant K. Bajpai
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
- Correspondence: ; Tel.: +370-6478-3364
| | - Rolandas Zakelis
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
| | - Mantas Deimantavicius
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
| | - Daiva Imbrasiene
- Department of Health Promotion and Rehabilitation, Lithuanian Sports University, LT-44221 Kaunas, Lithuania
- Institute of Physiology and Pharmacology, Lithuanian University of Health Sciences, LT-44307 Kaunas, Lithuania
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Bajpai BK, Preiksaitis A, Vosylius S, Rocka S. Association Between the Cerebral Autoregulation Index (Pressure Reactivity), Patient's Clinical Outcome, and Quality of ABP(t) and ICP(t) Signals for CA Monitoring. MEDICINA-LITHUANIA 2020; 56:medicina56030143. [PMID: 32245122 PMCID: PMC7143400 DOI: 10.3390/medicina56030143] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/12/2020] [Revised: 03/16/2020] [Accepted: 03/18/2020] [Indexed: 11/16/2022]
Abstract
Background and Objectives: The aim of this study was to explore the association between the cerebral autoregulation (CA) index, the pressure reactivity index (PRx), the patient’s clinical outcome, and the quality of arterial blood pressure (ABP(t)) and intracranial blood pressure (ICP(t)) signals by comparing two filtering methods to derive the PRx. Materials and Methods: Data from 60 traumatic brain injury (TBI) patients were collected. Moving averaging and FIR (Finite Impulse Response) filtering were performed on the ABP(t) and ICP(t) signals, and the PRx was estimated from both filtered datasets. Sensitivity, specificity, and receiver-operating characteristic (ROC) curves with the area under the curves (AUCs) were determined using patient outcomes as a reference. The outcome chosen for comparison among the two filtering methods were mortality and survival. Results: The FIR filtering approach, compared with clinical outcome, had a sensitivity of 70%, a specificity of 81%, and a level of significance p = 0.001 with an area under the curve (AUC) of 0.78. The moving average filtering method compared with the clinical outcome had a sensitivity of 58%, a specificity of 72%, and a level of significance p = 0.054, with an area under the curve (AUC) of 0.66. Conclusions: The FIR (optimal) filtering approach was found to be more sensitive for discriminating between two clinical outcomes, namely intact (survival) and impaired (death) cerebral autoregulation for TBI treatment decision making.
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Affiliation(s)
- Basant K. Bajpai
- Health Telematics Science Institute, Kaunas University of Technology, LT-51423 Kaunas, Lithuania
- Correspondence: ; Tel.: +37064783364
| | - Aidanas Preiksaitis
- Centre of Neurosurgery, Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, LT08661 Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Anesthesiology and Intensive Care, Institute of Clinical Medicine, Faculty of Medicine, Vilnius University, LT08661 Vilnius, Lithuania
| | - Saulius Rocka
- Centre of Neurosurgery, Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, LT08661 Vilnius, Lithuania
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35
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The CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative. Can J Neurol Sci 2020; 47:551-556. [PMID: 32174295 DOI: 10.1017/cjn.2020.54] [Citation(s) in RCA: 27] [Impact Index Per Article: 6.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022]
Abstract
In traumatic brain injury (TBI), future integration of multimodal monitoring of cerebral physiology and high-frequency signal processing techniques, with advanced neuroimaging, proteomic and genomic analysis, provides an opportunity to explore the molecular pathways involved in various aspects of cerebral physiologic dysfunction in vivo. The main issue with early and rapid discovery in this field of personalized medicine is the expertise and complexity of data involved. This brief communication highlights the CAnadian High-Resolution Traumatic Brain Injury (CAHR-TBI) Research Collaborative, which has been formed from centers with specific expertise in the area of high-frequency physiologic monitoring/processing, and outlines its objectives.
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36
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Ruesch A, Yang J, Schmitt S, Acharya D, Smith MA, Kainerstorfer JM. Estimating intracranial pressure using pulsatile cerebral blood flow measured with diffuse correlation spectroscopy. BIOMEDICAL OPTICS EXPRESS 2020; 11:1462-1476. [PMID: 32206422 PMCID: PMC7075623 DOI: 10.1364/boe.386612] [Citation(s) in RCA: 32] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 12/23/2019] [Revised: 02/11/2020] [Accepted: 02/12/2020] [Indexed: 05/08/2023]
Abstract
Measuring intracranial pressure (ICP) is necessary for the treatment of severe head injury but measurement systems are highly invasive and introduce risk of infection and complications. We developed a non-invasive alternative for quantifying ICP using measurements of cerebral blood flow (CBF) by diffuse correlation spectroscopy. The recorded cardiac pulsation waveform in CBF undergoes morphological changes in response to ICP changes. We used the pulse shape to train a randomized regression forest to estimate the underlying ICP and demonstrate in five non-human primates that DCS-based estimation can explain over 90% of the variance in invasively measured ICP.
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Affiliation(s)
- Alexander Ruesch
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Jason Yang
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Samantha Schmitt
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
- Neuroscience Institute, Carnegie Mellon University, 4400 Fifth Avenue, Pittsburgh, PA 15213, USA
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Deepshikha Acharya
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
| | - Matthew A. Smith
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
- Neuroscience Institute, Carnegie Mellon University, 4400 Fifth Avenue, Pittsburgh, PA 15213, USA
- Department of Ophthalmology, University of Pittsburgh, 203 Lothrop Street, Pittsburgh, PA 15213, USA
| | - Jana M. Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, 5000 Forbes Avenue, Pittsburgh, PA 15213, USA
- Neuroscience Institute, Carnegie Mellon University, 4400 Fifth Avenue, Pittsburgh, PA 15213, USA
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Abstract
Cerebral autoregulatory dysfunction after traumatic brain injury (TBI) is strongly linked to poor global outcome in patients at 6 months after injury. However, our understanding of the drivers of this dysfunction is limited. Genetic variation among individuals within a population gives rise to single-nucleotide polymorphisms (SNPs) that have the potential to influence a given patient's cerebrovascular response to an injury. Associations have been reported between a variety of genetic polymorphisms and global outcome in patients with TBI, but few studies have explored the association between genetic variants and cerebrovascular function after injury. In this Review, we explore polymorphisms that might play an important part in cerebral autoregulatory capacity after TBI. We outline a variety of SNPs, their biological substrates and their potential role in mediating cerebrovascular reactivity. A number of candidate polymorphisms exist in genes that are involved in myogenic, endothelial, metabolic and neurogenic vascular responses to injury. Furthermore, polymorphisms in genes involved in inflammation, the central autonomic response and cortical spreading depression might drive cerebrovascular reactivity. Identification of candidate genes involved in cerebral autoregulation after TBI provides a platform and rationale for further prospective investigation of the link between genetic polymorphisms and autoregulatory function.
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Gomez A, Dian J, Zeiler FA. Continuous and entirely non-invasive method for cerebrovascular reactivity assessment: technique and implications. J Clin Monit Comput 2020; 35:307-315. [PMID: 31989415 DOI: 10.1007/s10877-020-00472-4] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2019] [Accepted: 01/23/2020] [Indexed: 12/21/2022]
Abstract
Continuous cerebrovascular reactivity assessment in traumatic brain injury (TBI) has been limited by the need for invasive monitoring of either cerebral physiology or arterial blood pressure (ABP). This restricts the application of continuous measures to the acute phase of care, typically in the intensive care unit. It remains unknown if ongoing impairment of cerebrovascular reactivity occurs in the subacute and long-term phase, and if it drives ongoing morbidity in TBI. We describe an entirely non-invasive method for continuous assessment of cerebrovascular reactivity. We describe the technique for entirely non-invasive continuous assessment of cerebrovascular reactivity utilizing near-infrared spectroscopy (NIRS) and robotic transcranial Doppler (rTCD) technology, with details provided for NIRS. Recent advances in continuous high-frequency non-invasive ABP measurement, combined with NIRS or rTCD, can be employed to derive continuous and entirely non-invasive cerebrovascular reactivity metrics. Such non-invasive measures can be obtained during any aspect of patient care post-TBI, and even during outpatient follow-up, avoiding classical intermittent techniques and costly neuroimaging based metrics obtained only at specialized centers. This combination of technology and signal analytic techniques creates avenues for future investigation of the long-term consequences of cerebrovascular reactivity, integrating high-frequency non-invasive cerebral physiology, neuroimaging, proteomics and clinical phenotype at various stages post-injury.
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Affiliation(s)
- A Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - J Dian
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - F A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada. .,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada. .,Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada. .,Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Predictors of Intraspinal Pressure and Optimal Cord Perfusion Pressure After Traumatic Spinal Cord Injury. Neurocrit Care 2020; 30:421-428. [PMID: 30328047 PMCID: PMC6420421 DOI: 10.1007/s12028-018-0616-7] [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: 02/07/2023]
Abstract
Background/Objectives We recently developed techniques to monitor intraspinal pressure (ISP) and spinal cord perfusion pressure (SCPP) from the injury site to compute the optimum SCPP (SCPPopt) in patients with acute traumatic spinal cord injury (TSCI). We hypothesized that ISP and SCPPopt can be predicted using clinical factors instead of ISP monitoring. Methods Sixty-four TSCI patients, grades A–C (American spinal injuries association Impairment Scale, AIS), were analyzed. For 24 h after surgery, we monitored ISP and SCPP and computed SCPPopt (SCPP that optimizes pressure reactivity). We studied how well 28 factors correlate with mean ISP or SCPPopt including 7 patient-related, 3 injury-related, 6 management-related, and 12 preoperative MRI-related factors. Results All patients underwent surgery to restore normal spinal alignment within 72 h of injury. Fifty-one percentage had U-shaped sPRx versus SCPP curves, thus allowing SCPPopt to be computed. Thirteen percentage, all AIS grade A or B, had no U-shaped sPRx versus SCPP curves. Thirty-six percentage (22/64) had U-shaped sPRx versus SCPP curves, but the SCPP did not reach the minimum of the curve, and thus, an exact SCPPopt could not be calculated. In total 5/28 factors were associated with lower ISP: older age, excess alcohol consumption, nonconus medullaris injury, expansion duroplasty, and less intraoperative bleeding. In a multivariate logistic regression model, these 5 factors predicted ISP as normal or high with 73% accuracy. Only 2/28 factors correlated with lower SCPPopt: higher mean ISP and conus medullaris injury. In an ordinal multivariate logistic regression model, these 2 factors predicted SCPPopt as low, medium–low, medium–high, or high with only 42% accuracy. No MRI factors correlated with ISP or SCPPopt. Conclusions Elevated ISP can be predicted by clinical factors. Modifiable factors that may lower ISP are: reducing surgical bleeding and performing expansion duroplasty. No factors accurately predict SCPPopt; thus, invasive monitoring remains the only way to estimate SCPPopt. Electronic supplementary material The online version of this article (10.1007/s12028-018-0616-7) contains supplementary material, which is available to authorized users.
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40
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Zeiler FA, Ercole A, Beqiri E, Cabeleira M, Thelin EP, Stocchetti N, Steyerberg EW, Maas AIR, Menon DK, Czosnyka M, Smielewski P. Association between Cerebrovascular Reactivity Monitoring and Mortality Is Preserved When Adjusting for Baseline Admission Characteristics in Adult Traumatic Brain Injury: A CENTER-TBI Study. J Neurotrauma 2019; 37:1233-1241. [PMID: 31760893 DOI: 10.1089/neu.2019.6808] [Citation(s) in RCA: 48] [Impact Index Per Article: 9.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
Cerebral autoregulation, as measured using the pressure reactivity index (PRx), has been related to global patient outcome in adult patients with traumatic brain injury (TBI). To date, this has been documented without accounting for standard baseline admission characteristics and intracranial pressure (ICP). We evaluated this association, adjusting for baseline admission characteristics and ICP, in a multi-center, prospective cohort. We derived PRx as the correlation between ICP and mean arterial pressure in prospectively collected multi-center data from the High-Resolution Intensive Care Unit (ICU) cohort of the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) study. Multi-variable logistic regression models were analyzed to assess the association between global outcome (measured as either mortality or dichotomized Glasgow Outcome Score-Extended [GOSE]) and a range of covariates (IMPACT [International Mission for Prognosis and Analysis of Clinical Trials] Core and computed tomography [CT] variables, ICP, and PRx). Performance of these models in outcome association was compared using area under the receiver operating curve (AUC) and Nagelkerke's pseudo-R2. One hundred ninety-three patients had a complete data set for analysis. The addition of percent time above threshold for PRx improved AUC and displayed statistically significant increases in Nagelkerke's pseudo-R2 over the IMPACT Core and IMPACT Core + CT models for mortality. The addition of PRx monitoring to IMPACT Core ± CT + ICP models accounted for additional variance in mortality, when compared to models with IMPACT Core ± CT + ICP alone. The addition of cerebrovascular reactivity monitoring, through PRx, provides a statistically significant increase in association with mortality at 6 months. Our data suggest that cerebrovascular reactivity monitoring may provide complementary information regarding outcomes in TBI.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anaesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ari Ercole
- Division of Anaesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Eric P Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Ewout W Steyerberg
- Department of Public Health, Erasmus MC-University Medical Center Rotterdam, Rotterdam, the Netherlands and Department of Medical Statistics and Bioinformatics, Leiden University Medical Center, Leiden, the Netherlands
| | - Andrew I R Maas
- Department of Neurosurgery, University Hospital Antwerp, Edegem, Belgium
| | - David K Menon
- Division of Anaesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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41
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Estimation of pulsatile cerebral arterial blood volume based on transcranial doppler signals. Med Eng Phys 2019; 74:23-32. [DOI: 10.1016/j.medengphy.2019.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/30/2019] [Accepted: 07/28/2019] [Indexed: 11/20/2022]
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Petkus V, Preiksaitis A, Chaleckas E, Chomskis R, Zubaviciute E, Vosylius S, Rocka S, Rastenyte D, Aries MJ, Ragauskas A, Neumann JO. Optimal Cerebral Perfusion Pressure: Targeted Treatment for Severe Traumatic Brain Injury. J Neurotrauma 2019; 37:389-396. [PMID: 31583962 DOI: 10.1089/neu.2019.6551] [Citation(s) in RCA: 26] [Impact Index Per Article: 5.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Identification of individual therapy targets is critical for traumatic brain injury (TBI) patients. Clinical outcomes depend on cerebrovascular autoregulation (CA) impairment. Here, we compare the effectiveness of optimal cerebral perfusion pressure (CPPopt)-targeted therapy in younger (<45 years of age) and elderly (≥45 years of age) TBI patients. Single-center multi-modal invasive arterial blood pressure(t), intracranial pressure (ICP)(t), cerebral perfusion pressure CPP(t), and CPPopt(t) monitoring (n = 81) was performed. ICM+ software was used for continuous CPPopt(t) status assessment by identification of pressure reactivity index (PRx). The most significant prognostic factors were age, Glasgow Coma Scale, serum glucose, and duration of longest CA ompairment event (LCAI) when PRx(t) >0.5 within 24 h after admission. The modeled accuracies for favorable and unfavorable outcome prediction were 86.5% and 90.9%, respectively. Age above 45 years and averaged ICP during all monitoring time above 21.3 mm Hg was associated with unfavorable outcome of an individual patient. Averaged CPP values close to CPPopt were associated with a better outcome in younger patients. Averaged ΔCPPopt <-5.0 mm Hg, averaged PRx >0.36, and LCAI >100 min were significantly associated with mortality for the younger patients. The critical values of averaged PRx >0.26 and LCAI >61 min were significantly associated with mortality for the elderly group. Autoregulation-guided treatment was important for individual TBI management, especially in younger patients. Further randomized multi-center studies are needed to prove final benefit.
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Affiliation(s)
- Vytautas Petkus
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Aidanas Preiksaitis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania.,Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania.,Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Edvinas Chaleckas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Romanas Chomskis
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Erika Zubaviciute
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania
| | - Saulius Vosylius
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Saulius Rocka
- Clinic of Neurology and Neurosurgery, Faculty of Medicine, Vilnius University, Vilnius, Lithuania.,Department of Neurosurgery, Republic Vilnius University Hospital, Vilnius, Lithuania
| | - Daiva Rastenyte
- Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania
| | - Marcel J Aries
- Department of Intensive Care, University of Maastricht Medical Center, Maastricht, The Netherlands
| | - Arminas Ragauskas
- Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania
| | - Jan-Oliver Neumann
- Department of Neurosurgery, University Hospital Heidelberg, Heidelberg, Germany
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43
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Pistoia F, Carolei A, Bodien YG, Greenfield S, Kaplan S, Sacco S, Pistarini C, Casalena A, De Tanti A, Cazzulani B, Bellaviti G, Sarà M, Giacino J. The Comorbidities Coma Scale (CoCoS): Psychometric Properties and Clinical Usefulness in Patients With Disorders of Consciousness. Front Neurol 2019; 10:1042. [PMID: 31681139 PMCID: PMC6812466 DOI: 10.3389/fneur.2019.01042] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/23/2018] [Accepted: 09/13/2019] [Indexed: 11/18/2022] Open
Abstract
Although comorbidities have a well-known impact on the functional recovery of patients with disorders of consciousness, including coma, vegetative state (VS), and minimally conscious state (MCS), a specific tool for their assessment in this challenging group of patients is lacking. For this aim, a multistep process was used to develop and validate the Comorbidities Coma Scale (CoCoS) in a sample of 162 patients with a diagnosis of coma, VS or MCS admitted to four Acute Inpatient Rehabilitation Units. To establish the psychometric properties of the scale, content validity, and internal consistency were investigated through Exploratory Factor Analysis in the whole sample (n = 162). Interrater reliability, assessed by the weighted Cohen's kappa (Kw), and concurrent validity of the scale as compared to the Greenfield Scale, assessed by ρ Spearman's correlation coefficient, were investigated in a subsample of patients (n = 52) within two of the above units. Our findings provided evidence of a good content validity of the scale, with the identification of a 12-factor structure representing the different comorbid dimensions of the target population. Inter-rater reliability was excellent in both the rehabilitation units where the assessment was made [Kw 0.98 (95% CI 0.96–0.99)]. CoCoS total scores correlated significantly with total scores of the Greenfield Scale (ρ = 0.932, 95% CI 0.89–0.96; P < 0.0001) indicating that CoCoS has concurrent validity while being more informative about the specific pattern of comorbidities of these challenging patients. The CoCos is a new tool which standardizes the approach to assessment of comorbid conditions and reliably identifies the category and severity of each comorbidity detected. It may be used for both clinical and research applications.
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Affiliation(s)
- Francesca Pistoia
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Antonio Carolei
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Yelena G Bodien
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Boston, MA, United States.,Department of Neurology, Massachusetts General Hospital, Boston, MA, United States
| | - Sheldon Greenfield
- Health Policy Research Institute, University of California, Irvine, Irvine, CA, United States
| | - Sherrie Kaplan
- Health Policy Research Institute, University of California, Irvine, Irvine, CA, United States
| | - Simona Sacco
- Department of Biotechnological and Applied Clinical Sciences, Neurological Institute, University of L'Aquila, L'Aquila, Italy
| | - Caterina Pistarini
- Salvatore Maugeri Foundation, Scientific Institute of Nervi, Nervi, Italy
| | | | | | | | - Gianluca Bellaviti
- Salvatore Maugeri Foundation, Scientific Institute of Pavia, Pavia, Italy
| | - Marco Sarà
- Post-Coma Rehabilitative Unit, San Raffaele Hospital, Cassino, Italy
| | - Joseph Giacino
- Department of Physical Medicine and Rehabilitation, Spaulding Rehabilitation Hospital-Harvard Medical School, Boston, MA, United States
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44
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Smith M, Maas AIR. An algorithm for patients with intracranial pressure monitoring: filling the gap between evidence and practice. Intensive Care Med 2019; 45:1819-1821. [PMID: 31616963 DOI: 10.1007/s00134-019-05818-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2019] [Accepted: 10/09/2019] [Indexed: 11/25/2022]
Affiliation(s)
- Martin Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London, UK.
- Department of Medical Physics and Biomedical Engineering, University College, London, UK.
| | - Andrew I R Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
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Abstract
OBJECTIVES To describe the current state of the art regarding management of the critically ill trauma patient with an emphasis on initial management in the ICU. DATA SOURCES AND STUDY SELECTION A PubMed literature review was performed for relevant articles in English related to the management of adult humans with severe trauma. Specific topics included airway management, hemorrhagic shock, resuscitation, and specific injuries to the chest, abdomen, brain, and spinal cord. DATA EXTRACTION AND DATA SYNTHESIS The basic principles of initial management of the critically ill trauma patients include rapid identification and management of life-threatening injuries with the goal of restoring tissue oxygenation and controlling hemorrhage as rapidly as possible. The initial assessment of the patient is often truncated for procedures to manage life-threatening injuries. Major, open surgical procedures have often been replaced by nonoperative or less-invasive approaches, even for critically ill patients. Consequently, much of the early management has been shifted to the ICU, where the goal is to continue resuscitation to restore homeostasis while completing the initial assessment of the patient and watching closely for failure of nonoperative management, complications of procedures, and missed injuries. CONCLUSIONS The initial management of critically ill trauma patients is complex. Multiple, sometimes competing, priorities need to be considered. Close collaboration between the intensivist and the surgical teams is critical for optimizing patient outcomes.
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Beqiri E, Smielewski P, Robba C, Czosnyka M, Cabeleira MT, Tas J, Donnelly J, Outtrim JG, Hutchinson P, Menon D, Meyfroidt G, Depreitere B, Aries MJ, Ercole A. Feasibility of individualised severe traumatic brain injury management using an automated assessment of optimal cerebral perfusion pressure: the COGiTATE phase II study protocol. BMJ Open 2019; 9:e030727. [PMID: 31542757 PMCID: PMC6756360 DOI: 10.1136/bmjopen-2019-030727] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Individualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines. METHODS AND ANALYSIS CPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intracranial pressure monitoring are randomised within the first 24 hours of admission in neurocritical care unit. For the control arm, the CPP target is the Brain Trauma Foundation guidelines target (60-70 mm Hg); for the intervention group an automated CPP target is provided as the CPP at which the patient's cerebrovascular reactivity is best preserved (CPPopt). For a maximum of 5 days, attending clinicians review the CPP target 4-hourly. The main hypothesis of COGiTATE are: (1) in the intervention group the percentage of the monitored time with measured CPP within a range of 5 mm Hg above or below CPPopt will reach 36%; (2) the difference in between groups in daily therapy intensity level score will be lower or equal to 3. ETHICS AND DISSEMINATION Ethical approval has been obtained for each participating centre. The results will be presented at international scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02982122.
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Affiliation(s)
- Erta Beqiri
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
- Physiology and Transplantation, University of Milan, Milano, Italy
| | | | - Chiara Robba
- Anaesthesia and Intensive Care,Policlinico San Martino, IRCCS for Oncology and Neuroscience, University of Genoa, Genova, Italy
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | - Jeanette Tas
- Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | | | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Intensieve geneeskunde, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Bart Depreitere
- Intensieve geneeskunde, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Marcel J Aries
- Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Klein SP, De Sloovere V, Meyfroidt G, Depreitere B. Autoregulation assessment by direct visualisation of pial arterial blood flow in the piglet brain. Sci Rep 2019; 9:13333. [PMID: 31527671 PMCID: PMC6746693 DOI: 10.1038/s41598-019-50046-x] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Accepted: 09/04/2019] [Indexed: 12/22/2022] Open
Abstract
Impairment of cerebrovascular autoregulation (CAR) is common after brain injury, although the pathophysiology remains elusive. The mechanisms of vascular dysregulation, their impact on brain function, and potential therapeutic implications are still incompletely understood. Clinical assessment of CAR remains challenging. Observational studies suggest that CAR impairment is associated with worse outcomes, and that optimization of cerebral blood flow (CBF) by individual arterial blood pressure (ABP) targets could potentially improve outcome. We present a porcine closed cranial window model that measures the hemodynamic response of pial arterioles, the main site of CBF control, based on changes in their diameter and red blood cell velocity. This quantitative direct CAR assessment is compared to laser Doppler flow (LDF). CAR breakpoints are determined by segmented regression analysis and validated using LDF and brain tissue oxygen pressure. Using a standardized cortical impact, CAR impairment in traumatic brain injury can be studied using our method of combining pial arteriolar diameter and RBC velocity to quantify RBC flux in a large animal model. The model has numerous potential applications to investigate CAR physiology and pathophysiology of CAR impairment after brain injury, the impact of therapeutic interventions, drugs, and other confounders, or to develop personalized ABP management strategies.
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Affiliation(s)
- S P Klein
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium.
| | - V De Sloovere
- Department of Anesthesiology, University Hospitals Leuven, Leuven, Belgium
| | - G Meyfroidt
- Department of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - B Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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Zeiler FA, Ercole A, Beqiri E, Cabeleira M, Aries M, Zoerle T, Carbonara M, Stocchetti N, Smielewski P, Czosnyka M, Menon DK. Cerebrovascular reactivity is not associated with therapeutic intensity in adult traumatic brain injury: a CENTER-TBI analysis. Acta Neurochir (Wien) 2019; 161:1955-1964. [PMID: 31240583 PMCID: PMC6704258 DOI: 10.1007/s00701-019-03980-8] [Citation(s) in RCA: 40] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/03/2019] [Accepted: 06/11/2019] [Indexed: 02/03/2023]
Abstract
Background Impaired cerebrovascular reactivity in adult traumatic brain injury (TBI) is known to be associated with poor outcome. However, there has yet to be an analysis of the association between the comprehensively assessed intracranial hypertension therapeutic intensity level (TIL) and cerebrovascular reactivity. Methods Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived pressure reactivity index (PRx) as the moving correlation coefficient between slow-wave in ICP and mean arterial pressure, updated every minute. Mean daily PRx, and daily % time above PRx of 0 were calculated for the first 7 days of injury and ICU stay. This data was linked with the daily TIL-Intermediate scores, including total and individual treatment sub-scores. Daily mean PRx variable values were compared for each TIL treatment score via mean, standard deviation, and the Mann U test (Bonferroni correction for multiple comparisons). General fixed effects and mixed effects models for total TIL versus PRx were created to display the relation between TIL and cerebrovascular reactivity. Results A total of 249 patients with 1230 ICU days of high frequency physiology matched with daily TIL, were assessed. Total TIL was unrelated to daily PRx. Most TIL sub-scores failed to display a significant relationship with the PRx variables. Mild hyperventilation (p < 0.0001), mild hypothermia (p = 0.0001), high levels of sedation for ICP control (p = 0.0001), and use vasopressors for CPP management (p < 0.0001) were found to be associated with only a modest decrease in mean daily PRx or % time with PRx above 0. Conclusions Cerebrovascular reactivity remains relatively independent of intracranial hypertension therapeutic intensity, suggesting inadequacy of current TBI therapies in modulating impaired autoregulation. These findings support the need for investigation into the molecular mechanisms involved, or individualized physiologic targets (ICP, CPP, or Co2) in order to treat dysautoregulation actively. Electronic supplementary material The online version of this article (10.1007/s00701-019-03980-8) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- Department of Intensive Care, Maastricht UMC, Maastricht, Netherlands
| | - Tommaso Zoerle
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Armstead WM, Vavilala MS. Translational approach towards determining the role of cerebral autoregulation in outcome after traumatic brain injury. Exp Neurol 2019; 317:291-297. [PMID: 30928388 PMCID: PMC6544502 DOI: 10.1016/j.expneurol.2019.03.015] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2018] [Revised: 03/22/2019] [Accepted: 03/26/2019] [Indexed: 12/18/2022]
Abstract
Cerebral autoregulation is impaired after traumatic brain injury (TBI), contributing to poor outcome. In the context of the neurovascular unit, cerebral autoregulation contributes to neuronal cell integrity and clinically Glasgow Coma Scale is correlated to intactness of autoregulation after TBI. Cerebral Perfusion Pressure (CPP) is often normalized by use of vasoactive agents to increase mean arterial pressure (MAP) and thereby limit impairment of cerebral autoregulation and neurological deficits. However, current vasoactive agent choice used to elevate MAP to increase CPP after TBI is variable. Vasoactive agents, such as phenylephrine, dopamine, norepinephrine, and epinephrine, clinically have not sufficiently been compared regarding effect on CPP, autoregulation, and survival after TBI. The cerebral effects of these clinically commonly used vasoactive agents are incompletely understood. This review will describe translational studies using a more human like animal model (the pig) of TBI to identify better therapeutic strategies to improve outcome post injury. These studies also investigated the role of age and sex in outcome and mechanism(s) involved in improvement of outcome in the setting of TBI. Additionally, this review considers use of inhaled nitric oxide as a novel neuroprotective strategy in treatment of TBI.
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Affiliation(s)
- William M Armstead
- Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, PA l9l04, United States of America; Pharmacology, University of Pennsylvania, Philadelphia, PA l9l04, United States of America.
| | - Monica S Vavilala
- Department of Anesthesiology, Pediatrics, and Neurological Surgery, Harborview Injury Prevention and Research Center, University of Washington, Seattle, WA, United States of America
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50
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Patient-specific ICP Epidemiologic Thresholds in Adult Traumatic Brain Injury: A CENTER-TBI Validation Study. J Neurosurg Anesthesiol 2019; 33:28-38. [PMID: 31219937 DOI: 10.1097/ana.0000000000000616] [Citation(s) in RCA: 41] [Impact Index Per Article: 8.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
BACKGROUND Patient-specific epidemiologic intracranial pressure (ICP) thresholds in adult traumatic brain injury (TBI) have emerged, using the relationship between pressure reactivity index (PRx) and ICP, displaying stronger association with outcome over existing guideline thresholds. The goal of this study was to explore this relationship in a multi-center cohort in order to confirm the previous finding. METHODS Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit cohort, we derived individualized epidemiologic ICP thresholds for each patient using the relationship between PRx and ICP. Mean hourly dose of ICP was calculated for every patient for the following thresholds: 20, 22 mm Hg and the patient's individual ICP threshold. Univariate logistic regression models were created comparing mean hourly dose of ICP above thresholds to dichotomized outcome at 6 to 12 months, based on Glasgow Outcome Score-Extended (GOSE) (alive/dead-GOSE≥2/GOSE=1; favorable/unfavorable-GOSE 5 to 8/GOSE 1 to 4, respectively). RESULTS Individual thresholds were identified in 65.3% of patients (n=128), in keeping with previous results (23.0±11.8 mm Hg [interquartile range: 14.9 to 29.8 mm Hg]). Mean hourly dose of ICP above individual threshold provides superior discrimination (area under the receiver operating curve [AUC]=0.678, P=0.029) over mean hourly dose above 20 mm Hg (AUC=0.509, P=0.03) or above 22 mm Hg (AUC=0.492, P=0.035) on univariate analysis for alive/dead outcome at 6 to 12 months. The AUC for mean hourly dose above individual threshold trends to higher values for favorable/unfavorable outcome, but fails to reach statistical significance (AUC=0.610, P=0.060). This was maintained when controlling for baseline admission characteristics. CONCLUSIONS Mean hourly dose of ICP above individual epidemiologic ICP threshold has stronger associations with mortality compared with the dose above Brain Trauma Foundation defined thresholds of 20 or 22 mm Hg, confirming prior findings. Further studies on patient-specific epidemiologic ICP thresholds are required.
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