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Stroh JN, Foreman B, Bennett TD, Briggs JK, Park S, Albers DJ. Intracranial pressure-flow relationships in traumatic brain injury patients expose gaps in the tenets of models and pressure-oriented management. Front Physiol 2024; 15:1381127. [PMID: 39189028 PMCID: PMC11345185 DOI: 10.3389/fphys.2024.1381127] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2024] [Accepted: 06/28/2024] [Indexed: 08/28/2024] Open
Abstract
Background: The protocols and therapeutic guidance established for treating traumatic brain injury (TBI) in neurointensive care focus on managing cerebral blood flow (CBF) and brain tissue oxygenation based on pressure signals. The decision support process relies on assumed relationships between cerebral perfusion pressure (CPP) and blood flow, pressure-flow relationships (PFRs), and shares this framework of assumptions with mathematical intracranial hemodynamics models. These foundational assumptions are difficult to verify, and their violation can impact clinical decision-making and model validity. Methods: A hypothesis- and model-driven method for verifying and understanding the foundational intracranial hemodynamic PFRs is developed and applied to a novel multi-modality monitoring dataset. Results: Model analysis of joint observations of CPP and CBF validates the standard PFR when autoregulatory processes are impaired as well as unmodelable cases dominated by autoregulation. However, it also identifies a dynamical regime -or behavior pattern-where the PFR assumptions are wrong in a precise, data-inferable way due to negative CPP-CBF coordination over long timescales. This regime is of both clinical and research interest: its dynamics are modelable under modified assumptions while its causal direction and mechanistic pathway remain unclear. Conclusion: Motivated by the understanding of mathematical physiology, the validity of the standard PFR can be assessed a) directly by analyzing pressure reactivity and mean flow indices (PRx and Mx) or b) indirectly through the relationship between CBF and other clinical observables. This approach could potentially help to personalize TBI care by considering intracranial pressure and CPP in relation to other data, particularly CBF. The analysis suggests a threshold using clinical indices of autoregulation jointly generalizes independently set indicators to assess CA functionality. These results support the use of increasingly data-rich environments to develop more robust hybrid physiological-machine learning models.
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Affiliation(s)
- J. N. Stroh
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, United States
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, United States
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, United States
| | - Tellen D. Bennett
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Pediatric Intensive Care, Children’s Hospital of Colorado, Aurora, CO, United States
| | - Jennifer K. Briggs
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, United States
| | - Soojin Park
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
- Department of Neurology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, United States
| | - David J. Albers
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, United States
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, United States
- Department of Biomedical Informatics, Columbia University, New York, NY, United States
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Rodriguez EE, Zaccarelli M, Sterchele ED, Taccone FS. "NeuroVanguard": a contemporary strategy in neuromonitoring for severe adult brain injury patients. Crit Care 2024; 28:104. [PMID: 38561829 PMCID: PMC10985991 DOI: 10.1186/s13054-024-04893-4] [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: 01/05/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
Severe acute brain injuries, stemming from trauma, ischemia or hemorrhage, remain a significant global healthcare concern due to their association with high morbidity and mortality rates. Accurate assessment of secondary brain injuries severity is pivotal for tailor adequate therapies in such patients. Together with neurological examination and brain imaging, monitoring of systemic secondary brain injuries is relatively straightforward and should be implemented in all patients, according to local resources. Cerebral secondary injuries involve factors like brain compliance loss, tissue hypoxia, seizures, metabolic disturbances and neuroinflammation. In this viewpoint, we have considered the combination of specific noninvasive and invasive monitoring tools to better understand the mechanisms behind the occurrence of these events and enhance treatment customization, such as intracranial pressure monitoring, brain oxygenation assessment and metabolic monitoring. These tools enable precise intervention, contributing to improved care quality for severe brain injury patients. The future entails more sophisticated technologies, necessitating knowledge, interdisciplinary collaboration and resource allocation, with a focus on patient-centered care and rigorous validation through clinical trials.
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Affiliation(s)
- Edith Elianna Rodriguez
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Mario Zaccarelli
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elda Diletta Sterchele
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Terapia Intensiva e del Dolore, Scuola di Anestesia Rianimazione, Università degli Studi di Milano, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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3
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Stroh JN, Foreman B, Bennett TD, Briggs JK, Park S, Albers DJ. Intracranial pressure-flow relationships in traumatic brain injury patients expose gaps in the tenets of models and pressure-oriented management. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.17.24301445. [PMID: 38293069 PMCID: PMC10827274 DOI: 10.1101/2024.01.17.24301445] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
Background The protocols and therapeutic guidance established for treating traumatic brain injuries (TBI) in neurointensive care focus on managing cerebral blood flow (CBF) and brain tissue oxygenation based on pressure signals. The decision support process relies on assumed relationships between cerebral perfusion pressure (CPP) and blood flow, pressure-flow relationships (PFRs), and shares this framework of assumptions with mathematical intracranial hemodynamic models. These foundational assumptions are difficult to verify, and their violation can impact clinical decision-making and model validity. Method A hypothesis- and model-driven method for verifying and understanding the foundational intracranial hemodynamic PFRs is developed and applied to a novel multi-modality monitoring dataset. Results Model analysis of joint observations of CPP and CBF validates the standard PFR when autoregulatory processes are impaired as well as unmodelable cases dominated by autoregulation. However, it also identifies a dynamical regime -or behavior pattern- where the PFR assumptions are wrong in a precise, data-inferable way due to negative CPP-CBF coordination over long timescales. This regime is of both clinical and research interest: its dynamics are modelable under modified assumptions while its causal direction and mechanistic pathway remain unclear. Conclusions Motivated by the understanding of mathematical physiology, the validity of the standard PFR can be assessed a) directly by analyzing pressure reactivity and mean flow indices (PRx and Mx) or b) indirectly through the relationship between CBF and other clinical observables. This approach could potentially help personalize TBI care by considering intracranial pressure and CPP in relation to other data, particularly CBF. The analysis suggests a threshold using clinical indices of autoregulation jointly generalizes independently set indicators to assess CA functionality. These results support the use of increasingly data-rich environments to develop more robust hybrid physiological-machine learning models.
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Affiliation(s)
- J N Stroh
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, USA
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
- Gardner Neuroscience Institute, University of Cincinnati, Cincinnati, OH, USA
| | - Tellen D Bennett
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Pediatric Intensive Care, Children's Hospital of Colorado, Aurora, CO, USA
| | - Jennifer K Briggs
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, USA
| | - Soojin Park
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
- Department of Neurology, New York Presbyterian/Columbia University Irving Medical Center, New York, NY, USA
| | - David J Albers
- Department of Biomedical Informatics, University of Colorado Anschutz Medical Campus, Aurora, CO, USA
- Department of Bioengineering, University of Colorado Denver |Anschutz Medical Campus, Denver, CO, USA
- Department of Biomedical Informatics, Columbia University, New York, NY, USA
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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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Chen F, Zhang S, Li B, Zhang J, Ran M, Qi B. A review of invasive intracranial pressure monitoring following surgery for hypertensive cerebral hemorrhage. Front Neurol 2023; 14:1108722. [PMID: 37470003 PMCID: PMC10353852 DOI: 10.3389/fneur.2023.1108722] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2022] [Accepted: 06/07/2023] [Indexed: 07/21/2023] Open
Abstract
Hypertensive cerebral hemorrhage, the most common prevalent of spontaneous cerebral hemorrhage, poses a significant threat to patient mortality and morbidity, while therapeutic options remain limited, making the disease a burden not only for patients' families but also a major challenge for national healthcare systems. The elevation of intracranial pressure subsequent to hypertensive cerebral hemorrhage is a critical contributor to mortality. However, it often manifests before the onset of clinical symptoms, which are typically atypical, leading to delayed treatment and irreversible consequences for the patient. Hence, early detection of intracranial pressure variations can aid in timely, efficient, and precise treatment, reducing patient mortality. Invasive intracranial pressure monitoring enables real-time, accurate monitoring of intracranial pressure changes, providing clinicians with therapeutic guidance and overcoming the limitations of empirical treatment. This article aims to review the use of invasive intracranial pressure monitoring in postoperative hypertensive cerebral hemorrhage and hopes to contribute to clinical and scientific research.
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Affiliation(s)
- Fu Chen
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Shukui Zhang
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Bingzhen Li
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
| | - Jin Zhang
- Department of Neurosurgery, Sichuan Provincial People’s Hospital, University of Electronic Science and Technology of China, Chengdu, China
| | - Maoxin Ran
- Department of Hepatobiliary Surgery, Zhijin County People's Hospital, Bijie, China
| | - Bin Qi
- Department of Neurosurgery, The First Hospital of Jilin University, Changchun, China
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Nguyen A, Nguyen A, Hsu TI, Lew HD, Gupta N, Nguyen B, Mandavalli A, Diaz MJ, Lucke-Wold B. Neutrophil to Lymphocyte Ratio as a Predictor of Postoperative Outcomes in Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Diseases 2023; 11:diseases11010051. [PMID: 36975600 PMCID: PMC10047119 DOI: 10.3390/diseases11010051] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Revised: 03/05/2023] [Accepted: 03/10/2023] [Indexed: 03/17/2023] Open
Abstract
(1) Introduction: Traumatic brain injury (TBI) is a leading cause of injury and mortality worldwide, carrying an estimated cost of $38 billion in the United States alone. Neutrophil to lymphocyte ratio (NLR) has been investigated as a standardized biomarker that can be used to predict outcomes of TBI. The aim of this review was to determine the prognostic utility of NLR among patients admitted for TBI. (2) Methods: A literature search was conducted in PubMed, Scopus, and Web of Science in November 2022 to retrieve articles regarding the use of neutrophil to lymphocyte ratio (NLR) as a prognostic measure in traumatic brain injury (TBI) patients. Inclusion criteria included studies reporting outcomes of TBI patients with associated NLR values. Exclusion criteria were studies reporting only non-primary data, those insufficiently disaggregated to extract NLR data, and non-English or cadaveric studies. The Newcastle-Ottawa Scale was utilized to assess for the presence of bias in included studies. (3) Results: Following the final study selection 19 articles were included for quantitative and qualitative analysis. The average age was 46.25 years. Of the 7750 patients, 73% were male. Average GCS at presentation was 10.51. There was no significant difference in the NLR between surgical vs. non-surgical cohorts (SMD 2.41 95% CI −1.82 to 6.63, p = 0.264). There was no significant difference in the NLR between bleeding vs. non-bleeding cohorts (SMD 4.84 95% CI −0.26 to 9.93, p = 0.0627). There was a significant increase in the NLR between favorable vs. non-favorable cohorts (SMD 1.31 95% CI 0.33 to 2.29, p = 0.0090). (4) Conclusions: Our study found that NLR was only significantly predictive for adverse outcomes in TBI patients and not surgical treatment or intracranial hemorrhage, making it nonetheless an affordable alternative for physicians to assess patient prognosis.
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Affiliation(s)
- Andrew Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Alexander Nguyen
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Timothy I. Hsu
- School of Medicine, University of California, Irvine, CA 92617, USA
| | - Harrison D. Lew
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Nithin Gupta
- School of Medicine, Campbell University, Lillington, NC 27546, USA
| | - Brandon Nguyen
- Alix School of Medicine, Mayo Clinic, Scottsdale, AZ 85054, USA
| | - Akhil Mandavalli
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
| | - Michael J. Diaz
- College of Medicine, University of Florida, Gainesville, FL 32601, USA
- Correspondence:
| | - Brandon Lucke-Wold
- Department of Neurosurgery, University of Florida, Gainesville, FL 32608, USA
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Jung E, Ro YS, Ryu HH, Shin SD. Impact of cervical spine immobilization on clinical outcomes in traumatic brain injury patients according to prehospital mean arterial pressure: A multinational and multicenter observational study. Medicine (Baltimore) 2023; 102:e32849. [PMID: 36800598 PMCID: PMC9936025 DOI: 10.1097/md.0000000000032849] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/19/2023] Open
Abstract
Cervical spine immobilization (CSI) has been considered an essential part of first aid management after severe trauma; however, the routine use of CSI for traumatic brain injury (TBI) patients is a matter of debate. The purpose of our study was to analyze the effect of CSI on the clinical outcomes of TBI patients and to analyze whether this effect depends on the prehospital mean arterial pressure (MAP) This was a prospective multi-national, multi-center cohort study using Pan-Asian trauma outcome study registry in Asian-Pacific, conducted on adult trauma patients. The main exposure was the implementation of CSI before hospital arrival. The main outcome was poor functional recovery at hospital discharge measured by the modified rankin scale. We performed multilevel logistic regression analysis to estimated the effect size of CSI for study outcomes. Interaction analysis between CSI and MAP on study outcomes were also conducted. CSI for TBI patients is significantly associated with an increased poor functional outcome (adjusted odd ratio, 95% confidence intervals: 1.23 [1.03 - 1.44]). The association of CSI with poor functional outcomes was maintained only in patients with decreased prehospital MAP (1.38 [1.14 - 1.56]), but not in patients with normal MAP (1.12 [0.93 - 1.24]) (P for interaction < .05). Routine use of CSI for patients with TBI, but without cervical spine injury, is associated with poor functional outcomes, but is significant only when the MAP, measured at the scene, was decreased.
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Affiliation(s)
- Eujene Jung
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
| | - Young Sun Ro
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
| | - Hyun Ho Ryu
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, Korea
- Department of Emergency Medicine, Chonnam National University Hospital, Gwangju, KoreaMedicine, Chonnam National University, Gwangju, Korea
- * Correspondence: Hyun Ho Ryu, Department of Emergency Medicine, Chonnam National University Hospital, 42, Jebong-ro, Dong-Gu, Gwangju 61469, Korea (e-mail: )
| | - Sang Do Shin
- Department of Emergency Medicine, Seoul National University Hospital, Seoul, Korea
- Department of Emergency Medicine, Seoul National University, Seoul, Korea
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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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Navarro JC, Kofke WA. Perioperative Management of Acute Central Nervous System Injury. Perioper Med (Lond) 2022. [DOI: 10.1016/b978-0-323-56724-4.00024-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023] Open
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10
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Impact of Head-of-Bed Posture on Brain Oxygenation in Patients with Acute Brain Injury: A Prospective Cohort Study. Neurocrit Care 2021; 35:662-668. [PMID: 34312789 PMCID: PMC8312355 DOI: 10.1007/s12028-021-01240-1] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2020] [Accepted: 03/20/2021] [Indexed: 12/31/2022]
Abstract
Background Therapeutic head positioning plays a role in the management of patients with acute brain injury. Although intracranial pressure (ICP) is typically lower in an upright posture than in a flat position, limited data exist concerning the effect of upright positioning on brain oxygenation and circulation. We sought to determine the impact of supine (0°) and semirecumbent (15° and 30°) postures on ICP, brain oxygenation, and brain circulation. Methods An observational cohort study was conducted between February 2012 and September 2015. Twenty-three patients with severe acute brain injury were successively observed at head elevations of 30°, 15°, and 0°. Postural-induced changes in ICP, cerebral perfusion pressure, brain tissue oxygenation pressure, and transcranial Doppler findings were simultaneously measured during three repeated experiments: 24 h after admission to the intensive care unit (exp1), 24 h later (exp2), and 96 h later (exp3). Cerebral perfusion pressure, arterial blood gases, hemoglobin content, and body temperature remained unchanged during the three experiments. Results Using linear random-slope mixed models, we found that during the early phase of acute brain injury (exp1), lowering the head posture from 30° to 15°, and then to 0°, was associated with a gradual mean ICP increase of 2.6 mm Hg (1.4–3.7 mm Hg; P < 0.001); and from 30° to 0°, an increase of 7.4 mm Hg (6.3–8.6 mm Hg; P < 0.001). Furthermore, brain tissue oxygenation pressure and mean blood flow velocity improved when the head posture was lowered from 30° to 0° by 1.2 mm Hg (0.2–2.3 mm Hg) and 4.1 cm/s (0.0–8.2 cm/s), respectively (both P < 0.05). Conclusions Changing the positioning of stable patients with acute brain injury resulted in opposite changes of ICP versus brain oxygenation and circulation. This information supports the concept of an individualized approach to head positioning that is based on the multimodal monitoring of brain parameters.
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Kim TH, Kim H, Hong KJ, Shin SD, Kim HC, Park YJ, Ro YS, Song KJ, Kim KH, Choi DS, Kang HJ. Prediction of cerebral perfusion pressure during CPR using electroencephalogram in a swine model of ventricular fibrillation. Am J Emerg Med 2021; 45:137-143. [PMID: 33721657 DOI: 10.1016/j.ajem.2021.02.051] [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: 12/28/2020] [Revised: 02/11/2021] [Accepted: 02/21/2021] [Indexed: 10/22/2022] Open
Abstract
BACKGROUND Measuring the quality of cardiopulmonary resuscitation (CPR) is important for improving outcomes in cardiac arrest. Cerebral perfusion pressure (CePP) could represent cerebral circulation during CPR, but it is difficult to measure non-invasively. In this study, we developed the electroencephalogram (EEG) based brain index (EBRI) derived from EEG signals by machine learning techniques, which could estimate CePP accurately in a porcine cardiac arrest model. METHODS We conducted a randomised crossover study using nine female pigs. After 1 min of untreated ventricular fibrillation, we performed CPR with 12 different 2-min tilting angle sessions, including two different head-up tilt (HUT) angles (30°, 15°) twice, horizontal angle (0°) four times and two different head-down tilt (HDT) angles (-15°, -30°) twice with the random order. We collected EEG signals using a single channel EEG electrode in real-time during CPR. We derived the EBRI models to predict the CePP classified by the 5 or 10 groups using three different machine learning algorithms, including the support vector machine (SVM), k-nearest neighbour (KNN) and random forest classification (RFC) method. We assessed the accuracy, sensitivity and specificity of each model. RESULTS The accuracy of the EBRI model using an SVM algorithm in the 5-group CePP classification was 0.935 with a standard deviation (SD) from 0.923 to 0.946. The accuracy in the 10-group classification was 0.904 (SD: 0.896, 0.913). The accuracy of the EBRI using the KNN method in the 5-group classification was 0.927 (SD: 0.920, 0933) and in the 10-group was 0.894 (SD: 0.880, 0.907). The accuracy of the RFC algorithm was 0.947 (SD: 0.931, 0.963) in the 5-group classification and 0.920 (SD: 0.911, 0.929) in the 10-group classification. CONCLUSION We developed the EBRI model using non-invasive acquisition of EEG signals to predict CePP during CPR. The accuracy the EBRI model was 0.935, 0.927 and 0.947 for each machine learning algorithm, and the EBRI could be used as a surrogate indicator for measuring cerebral perfusion during CPR.
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Affiliation(s)
- Tae Han Kim
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Heejin Kim
- Interdisciplinary Program in Bioengineering, Graduate School, Seoul National University, Seoul, Republic of Korea.
| | - Ki Jeong Hong
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea.
| | - Sang Do Shin
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hee Chan Kim
- Interdisciplinary Program in Bioengineering, Graduate School, Seoul National University, Seoul, Republic of Korea; Institute of Medical and Biological Engineering, Medical Research Center, Seoul National University, Seoul, Republic of Korea; Department of Biomedical Engineering, College of Medicine, Seoul National University, Seoul, Republic of Korea.
| | - Yong Joo Park
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Young Sun Ro
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Kyoung Jun Song
- Department of Emergency Medicine, Seoul Metropolitan Government Seoul National University Boramae Medical Center, Seoul, Republic of Korea; Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Ki Hong Kim
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea; Department of Emergency Medicine, Seoul National University Hospital, Seoul, Republic of Korea
| | - Dong Sun Choi
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
| | - Hyun Jeong Kang
- Laboratory of Emergency Medical Services, Biomedical Research Institute, Seoul National University Hospital, Seoul, Republic of Korea
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Stead GA, Cresswell FV, Jjunju S, Oanh PK, Thwaites GE, Donovan J. The role of optic nerve sheath diameter ultrasound in brain infection. eNeurologicalSci 2021; 23:100330. [PMID: 33728383 PMCID: PMC7935708 DOI: 10.1016/j.ensci.2021.100330] [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: 12/21/2020] [Accepted: 02/18/2021] [Indexed: 11/24/2022] Open
Abstract
Brain infections cause significant morbidity and mortality worldwide, especially in resource-limited settings with high HIV co-infection rates. Raised intracranial pressure [ICP] may complicate brain infection and worsen neurological injury, yet invasive ICP monitoring is often unavailable. Optic nerve sheath diameter [ONSD] ultrasound may allow detection of raised ICP at the bedside; however, pathology in brain infection is different to traumatic brain injury, in which most studies have been performed. The use of ONSD ultrasound has been described in tuberculous meningitis, cryptococcal meningitis and cerebral malaria; however correlation with invasive ICP measurement has not been performed. Normal optic nerve sheath values are not yet established for most populations, and thresholds for clinical intervention cannot be assumed to match those used in non-infective brain pathology. ONSD ultrasound may be suitable for use in resource-limited settings by clinicians with limited ultrasound training. Standardisation of scanning technique, consensus on normal ONSD values, and action on abnormal results, are areas for future research. This scoping review examines the role of ONSD ultrasound in brain infection. We discuss pathophysiology, and describe the rationale, practicalities, and challenges of utilising ONSD ultrasound for brain infection monitoring and management. We discuss the existing evidence base for this technique, and identify knowledge gaps and future research priorities.
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Key Words
- AIDS, Acquired immunodeficiency syndrome
- Brain infection
- CSF, Cerebrospinal fluid
- HIV, Human immunodeficiency virus
- ICP, Intracranial pressure
- IQR, Interquartile range
- IRIS, Immune reconstitution inflammatory syndrome
- LP, Lumbar puncture
- MAP, Mean arterial pressure
- Meningitis
- ONSD, Optic nerve sheath diameter
- Optic nerve sheath diameter
- ROC, Receiver-operator characteristic
- Raised intracranial pressure
- SD, Standard deviation
- TB meningitis, Tuberculous meningitis
- TBI, Traumatic brain injury
- Ultrasound
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Affiliation(s)
| | - Fiona V. Cresswell
- Infectious Diseases Institute, Kampala, Uganda
- Clinical Research Department London School of Hygiene and Tropical Medicine, London, United Kingdom
- Medical Research Council – Uganda Virus Research Institute - London School of Hygiene and Tropical Medicine Uganda Research Unit, Entebbe, Uganda
| | | | - Pham K.N. Oanh
- Hospital for Tropical Diseases, Ho Chi Minh City, Viet Nam
| | - Guy E. Thwaites
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
| | - Joseph Donovan
- Centre for Tropical Medicine and Global Health, Nuffield Department of Medicine, University of Oxford, Oxford, United Kingdom
- Oxford University Clinical Research Unit, Centre for Tropical Medicine, Ho Chi Minh City, Viet Nam
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Belov V, Appleton J, Levin S, Giffenig P, Durcanova B, Papisov M. Large-Volume Intrathecal Administrations: Impact on CSF Pressure and Safety Implications. Front Neurosci 2021; 15:604197. [PMID: 33935624 PMCID: PMC8079755 DOI: 10.3389/fnins.2021.604197] [Citation(s) in RCA: 14] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/08/2020] [Accepted: 03/24/2021] [Indexed: 12/04/2022] Open
Abstract
The increasing number of studies demonstrates the high potency of the intrathecal (IT) route for the delivery of biopharmaceuticals to the central nervous system (CNS). Our earlier data exhibited that both the infused volume and the infusion rate can regulate the initial disposition of the administered solute within the cerebrospinal fluid (CSF). This disposition is one of key factors in defining the subsequent transport of the solute to its intended target. On the other hand, fast additions of large volumes of liquid to the CSF inevitably raise the CSF pressure [a.k.a. intracranial pressure (ICP)], which may in turn lead to adverse reactions if the physiologically delimited threshold is exceeded. While long-term biological effects of elevated ICP (hydrocephalus) are known, the safety thresholds pertaining to short-term ICP elevations caused by IT administrations have not yet been characterized. This study aimed to investigate the dynamics of ICP in rats and non-human primates (NHPs) with respect to IT infusion rates and volumes. The safety regimes were estimated and analyzed across species to facilitate the development of translational large-volume IT therapies. The data revealed that the addition of a liquid to the CSF raised the ICP in a rate and volume-dependent manner. At low infusion rates (<0.12 ml/min in rats and <2 ml/min in NHPs), NHPs and rats displayed similar tolerance patterns. Specifically, safe accommodations of such added volumes were mainly facilitated by the accelerated pressure-dependent CSF drainage into the blood, with I stabilizing at different levels below the safety threshold of 28 ± 4 mm Hg in rats and 50 ± 5 mm Hg in NHPs. These ICPs were safely tolerated for extended durations (of at least 2–25 min). High infusion rates (including boluses) caused uncompensated exponential ICP elevations rapidly exceeding the safety thresholds. Their tolerance was species-dependent and was facilitated by the compensatory role of the varied components of craniospinal compliance while not excluding the possibility of other contributing factors. In conclusion, large volumes of liquids can safely be delivered via IT routes provided that ICP is monitored as a safety factor and cross-species physiological differences are accounted for.
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Affiliation(s)
- Vasily Belov
- Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Shriners Hospitals for Children-Boston, Boston, MA, United States
| | | | - Stepan Levin
- Massachusetts General Hospital, Boston, MA, United States
| | - Pilar Giffenig
- Massachusetts General Hospital, Boston, MA, United States
| | | | - Mikhail Papisov
- Massachusetts General Hospital, Boston, MA, United States.,Harvard Medical School, Boston, MA, United States.,Shriners Hospitals for Children-Boston, Boston, MA, United States
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Musick S, Alberico A. Neurologic Assessment of the Neurocritical Care Patient. Front Neurol 2021; 12:588989. [PMID: 33828517 PMCID: PMC8019734 DOI: 10.3389/fneur.2021.588989] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2020] [Accepted: 03/02/2021] [Indexed: 11/30/2022] Open
Abstract
Sedation is a ubiquitous practice in ICUs and NCCUs. It has the benefit of reducing cerebral energy demands, but also precludes an accurate neurologic assessment. Because of this, sedation is intermittently stopped for the purposes of a neurologic assessment, which is termed a neurologic wake-up test (NWT). NWTs are considered to be the gold-standard in continued assessment of brain-injured patients under sedation. NWTs also produce an acute stress response that is accompanied by elevations in blood pressure, respiratory rate, heart rate, and ICP. Utilization of cerebral microdialysis and brain tissue oxygen monitoring in small cohorts of brain-injured patients suggests that this is not mirrored by alterations in cerebral metabolism, and seldom affects oxygenation. The hard contraindications for the NWT are preexisting intracranial hypertension, barbiturate treatment, status epilepticus, and hyperthermia. However, hemodynamic instability, sedative use for primary ICP control, and sedative use for severe agitation or respiratory distress are considered significant safety concerns. Despite ubiquitous recommendation, it is not clear if additional clinically relevant information is gleaned through its use, especially with the contemporaneous utilization of multimodality monitoring. Various monitoring modalities provide unique and pertinent information about neurologic function, however, their role in improving patient outcomes and guiding treatment plans has not been fully elucidated. There is a paucity of information pertaining to the optimal frequency of NWTs, and if it differs based on type of injury. Only one concrete recommendation was found in the literature, exemplifying the uncertainty surrounding its utility. The most common sedative used and recommended is propofol because of its rapid onset, short duration, and reduction of cerebral energy requirements. Dexmedetomidine may be employed to facilitate serial NWTs, and should always be used in the non-intubated patient or if propofol infusion syndrome (PRIS) develops. Midazolam is not recommended due to tissue accumulation and residual sedation confounding a reliable NWT. Thus, NWTs are well-tolerated in selected patients and remain recommended as the gold-standard for continued neuromonitoring. Predicated upon one expert panel, they should be performed at least one time per day. Propofol or dexmedetomidine are the main sedative choices, both enabling a rapid awakening and consistent NWT.
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Affiliation(s)
- Shane Musick
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
| | - Anthony Alberico
- Department of Neurosurgery, Joan C. Edwards School of Medicine, Marshall University, Huntington, WV, United States
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Kang T, Park SY, Lee SH, Park JH, Suh SW. Assessing changes in cervical epidural pressure during biportal endoscopic lumbar discectomy. J Neurosurg Spine 2021; 34:196-202. [PMID: 33126221 DOI: 10.3171/2020.6.spine20586] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/13/2020] [Accepted: 06/18/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Biportal endoscopic spinal surgery has been performed for several years, and its effectiveness is well known; however, no studies on its safety, specifically intracranial pressure, have been conducted to date. The authors sought to evaluate the effect of biportal endoscopic lumbar discectomy on intracranial pressure by monitoring cervical epidural pressure (CEP) changes throughout the procedure. METHODS Twenty patients undergoing single-level biportal endoscopic lumbar discectomy were enrolled in this study. CEPs were monitored throughout the procedure, consisting of phase 1, establishing the surgical portal and working space; phase 2, performing decompression and discectomy; and phase 3, turning off the fluid irrigation system. After discectomy was completed, the authors evaluated changes in CEP as the irrigation pressure increased serially by adding phase 4, increasing irrigation pressure with outflow open; and phase 5, increasing irrigation pressure with outflow closed. RESULTS The mean baseline CEP was measured as 16.65 mm Hg. In phase 1, the mean CEP was 17.3 mm Hg, which was not significantly different from the baseline CEP. In phase 2, the mean CEP abruptly increased up to 35.1 mm Hg when the epidural space was first connected with the working space, followed by stabilization of the CEP at 31.65 mm Hg. In phase 4, the CEP increased as the inflow pressure increased, showing a linear correlation, but not in phase 5. No patients experienced neurological complications. CONCLUSIONS It is important to ensure that irrigation fluid is not stagnant and is maintained continuously. More attention must be paid to keeping pressures low when opening the epidural space.
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Intracranial pressure monitoring following traumatic brain injury: evaluation of indications, complications, and significance of follow-up imaging-an exploratory, retrospective study of consecutive patients at a level I trauma center. Eur J Trauma Emerg Surg 2020; 48:863-870. [PMID: 33351163 PMCID: PMC7754179 DOI: 10.1007/s00068-020-01570-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2020] [Accepted: 12/02/2020] [Indexed: 12/04/2022]
Abstract
Background Measurement of intracranial pressure (ICP) is an essential part of clinical management of severe traumatic brain injury (TBI). However, clinical utility and impact on clinical outcome of ICP monitoring remain controversial. Follow-up imaging using cranial computed tomography (CCT) is commonly performed in these patients. This retrospective cohort study reports on complication rates of ICP measurement in severe TBI patients, as well as on findings and clinical consequences of follow-up CCT. Methods We performed a retrospective clinical chart review of severe TBI patients with invasive ICP measurement treated at an urban level I trauma center between January 2007 and September 2017. Results Clinical records of 213 patients were analyzed. The mean Glasgow Coma Scale (GCS) on admission was 6 with an intra-hospital mortality of 20.7%. Overall, complications in 12 patients (5.6%) related to the invasive ICP-measurement were recorded of which 5 necessitated surgical intervention. Follow-up CCT scans were performed in 192 patients (89.7%). Indications for follow-up CCTs included routine imaging without clinical deterioration (n = 137, 64.3%), and increased ICP values and/or clinical deterioration (n = 55, 25.8%). Follow-up imaging based on clinical deterioration and increased ICP values were associated with significantly increased likelihoods of worsening of CCT findings compared to routinely performed CCT scans with an odds ratio of 5.524 (95% CI 1.625–18.773) and 6.977 (95% CI 3.262–14.926), respectively. Readings of follow-up CCT imaging resulted in subsequent surgical intervention in six patients (3.1%). Conclusions Invasive ICP-monitoring in severe TBI patients was safe in our study population with an acceptable complication rate. We found a high number of follow-up CCT. Our results indicate that CCT imaging in patients with invasive ICP monitoring should only be considered in patients with elevated ICP values and/or clinical deterioration.
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Intracranial Pressure Monitoring via External Ventricular Drain: Are We Waiting Long Enough Before Recording the Real Value? J Neurosci Nurs 2020; 52:37-42. [PMID: 31899715 DOI: 10.1097/jnn.0000000000000487] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
BACKGROUND External ventricular drain (EVD) is a standard approach for both monitoring intracranial pressure (ICP) and draining cerebrospinal fluid (CSF) for patients with subarachnoid hemorrhage. Documenting an accurate ICP value is important to assess the status of the brain, which would require the EVD system to be leveled properly and closed to CSF drainage for an adequate period. It is suggested that a minimum period of 5-minute EVD closure is needed before documenting a true ICP; however, there is no commonly agreed upon standard for documenting ICP. To obtain an insight into how well the intermittent EVD clamping procedure is performed for ICP documentation, we conducted a retrospective analysis of ICP recordings obtained through EVD from 107 patients with subarachnoid hemorrhage. METHODS The EVD was kept open for continuous CSF drainage and then intermittently closed for ICP documentation. For each EVD closure, mean ICP, standard deviation of ICP, duration of EVD closure, and time interval between 2 adjacent EVD closures were studied. The total number of EVD closures was calculated for each patient. We developed an algorithm to evaluate whether ICP reached a new equilibrium before the EVD was reopened to drainage. The percentage of EVD closures that reach the equilibrium was calculated. RESULTS The 107 patients had 32 755 EVD closures in total, among which 65.9% instances lasted less than 1 minute and only 16.3% of all the EVD closure episodes lasted longer than 5 minutes. The median duration of each EVD closure was 25 seconds (interquartile range, 10.2 seconds to 2.33 minutes). Only 22.9% of the EVD closures reached ICP equilibrium before EVD reopening. CONCLUSION A standard guideline and proper training are needed for bedside nurses, and a potential tool that can render ICP trend at a proper scale at bedside would help clinicians correctly document ICP.
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Kleffmann J, Pahl R, Ferbert A, Roth C. Factors influencing intracranial pressure (ICP) during percutaneous tracheostomy. Clin Neurol Neurosurg 2020; 195:105869. [PMID: 32353664 DOI: 10.1016/j.clineuro.2020.105869] [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: 06/30/2019] [Revised: 04/20/2020] [Accepted: 04/21/2020] [Indexed: 10/24/2022]
Abstract
OBJECTIVES Percutaneous tracheostomy (PT) is common on ICUs. An increase of intracranial pressure (ICP) can be observed in patients with acute cerebral diseases. Factors determining ICP increase remain unclear. PATIENTS AND METHODS Data for all PTs were collected prospectively. ICP, cerebral perfusion pressure (CPP), mean arterial pressure (MAP), peripheral oxygen saturation (SpO2), and heart rate (HR) were monitored continuously every minute. Primary outcome parameter was an increase of ICP during PT (ICP > 20 mmHg). Influencing factors were evaluated by the means of logistic regression analysis: Body mass index (BMI), age, gender, physician performing the procedure (neurologist vs. neurosurgeon), duration of the procedure, underlying disease, duration of mechanical ventilation, and baseline ICP value before the procedure. RESULTS A total of 175 PTs were performed during the observation period between 2010 and 2013. Of these, 54 received ICP monitoring and were included into this study. Median initial ICP value was 10.4 mmHg and rose significantly to a median value of 18.4 mmHg (p < 0.05). In 21 patients (38,9%) an increase of median ICP above 20 mmHg was seen during at least one interval. Comparing patients with and without pathological ICP increase a significant difference between the two groups was only observed for patients with an increased baseline ICP above 15 mmHg. All other factors had no significant influence on the development of a pathological ICP peaks during PT. CONCLUSION Percutaneous tracheostomies in patients with cerebral injury leads to a significant increase of ICP during the procedure. Patients with a baseline ICP > 15 mmHg are at risk to develop harmful ICP crises.
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Affiliation(s)
- Jens Kleffmann
- Neurocenter Kassel, Marburger Str. 85, 34127 Kassel, Germany; Department of Neurosurgery, Klinikum Kassel, Mönchebergstraße 41-43, 34125 Kassel, Germany
| | - Roman Pahl
- Institute of Medical Biometry and Epidemiology (IMBE), Philipps University Marburg, Bunsenstraße 3, 35037 Marburg, Germany
| | - Andreas Ferbert
- Department of Neurology, DRK-Kliniken Nordhessen, Hansteinstraße 29, 34121 Kassel, Germany
| | - Christian Roth
- Department of Neurology, DRK-Kliniken Nordhessen, Hansteinstraße 29, 34121 Kassel, Germany; Department of Neurology, Philipps University Marburg, Baldingerstraße, 35037 Marburg, Germany.
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Zusman BE, Kochanek PM, Jha RM. Cerebral Edema in Traumatic Brain Injury: a Historical Framework for Current Therapy. Curr Treat Options Neurol 2020; 22:9. [PMID: 34177248 PMCID: PMC8223756 DOI: 10.1007/s11940-020-0614-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
PURPOSE OF REVIEW The purposes of this narrative review are to (1) summarize a contemporary view of cerebral edema pathophysiology, (2) present a synopsis of current management strategies in the context of their historical roots (many of which date back multiple centuries), and (3) discuss contributions of key molecular pathways to overlapping edema endophenotypes. This may facilitate identification of important therapeutic targets. RECENT FINDINGS Cerebral edema and resultant intracranial hypertension are major contributors to morbidity and mortality following traumatic brain injury. Although Starling forces are physical drivers of edema based on differences in intravascular vs extracellular hydrostatic and oncotic pressures, the molecular pathophysiology underlying cerebral edema is complex and remains incompletely understood. Current management protocols are guided by intracranial pressure measurements, an imperfect proxy for cerebral edema. These include decompressive craniectomy, external ventricular drainage, hyperosmolar therapy, hypothermia, and sedation. Results of contemporary clinical trials assessing these treatments are summarized, with an emphasis on the gap between intermediate measures of edema and meaningful clinical outcomes. This is followed by a brief statement summarizing the most recent guidelines from the Brain Trauma Foundation (4th edition). While many molecular mechanisms and networks contributing to cerebral edema after TBI are still being elucidated, we highlight some promising molecular mechanism-based targets based on recent research including SUR1-TRPM4, NKCC1, AQP4, and AVP1. SUMMARY This review outlines the origins of our understanding of cerebral edema, chronicles the history behind many current treatment approaches, and discusses promising molecular mechanism-based targeted treatments.
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Affiliation(s)
- Benjamin E. Zusman
- University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Institute for Clinical Research Education, University of Pittsburgh, Pittsburgh, PA, USA
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Patrick M. Kochanek
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Anesthesiology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- UPMC Children’s Hospital of Pittsburgh, UPMC, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
| | - Ruchira M. Jha
- Clinical and Translational Science Institute, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, John G. Rangos Research Center, Pittsburgh, PA, USA
- Department of Neurology, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Neurological Surgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
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Abstract
OBJECTIVE This study applied a new external ventricular catheter, which allows intracranial pressure (ICP) monitoring and cerebral spinal fluid (CSF) drainage simultaneously, to study cerebral vascular responses during acute CSF drainage. METHODS Six patients with 34 external ventricular drain (EVD) opening sessions were retrospectively analyzed. A published algorithm was used to extract morphological features of ICP recordings, and a template-matching algorithm was applied to calculate the likelihood of cerebral vasodilation index (VDI) and cerebral vasoconstriction index (VCI) based on the changes of ICP waveforms during CSF drainage. Power change (∆P) of ICP B-waves after EVD opening was also calculated. Cerebral autoregulation (CA) was assessed through phase difference between arterial blood pressure (ABP) and ICP using a previously published wavelet-based algorithm. RESULTS The result showed that acute CSF drainage reduced mean ICP (P = 0.016) increased VCI (P = 0.02) and reduced ICP B-wave power (P = 0.016) significantly. VCI reacted to ICP changes negatively when ICP was between 10 and 25 mmHg, and VCI remained unchanged when ICP was outside the 10-25 mmHg range. VCI negatively (r = - 0.44) and VDI positively (r = 0.82) correlated with ∆P of ICP B-waves, indicating that stronger vasoconstriction resulted in bigger power drop in ICP B-waves. Better CA prior to EVD opening triggered bigger drop in the power of ICP B-waves (r = - 0.612). CONCLUSIONS This study demonstrates that acute CSF drainage reduces mean ICP, and results in vasoconstriction which can be detected through an index, VCI. Cerebral vessels actively respond to ICP changes or cerebral perfusion pressure (CPP) changes in a certain range; beyond which, the vessels are insensitive to the changes in ICP and CPP.
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Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos. Neurocirugia (Astur) 2020; 31:24-36. [DOI: 10.1016/j.neucir.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 01/20/2023]
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Optimización del manejo del paciente neuroquirúrgico en Medicina Intensiva. Med Intensiva 2019; 43:489-496. [DOI: 10.1016/j.medin.2019.02.011] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/30/2018] [Revised: 02/18/2019] [Accepted: 02/21/2019] [Indexed: 01/26/2023]
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Tse B, Burbridge MA, Jaffe RA, Brock-Utne J. Inaccurate Blood Pressure Readings in the Intensive Care Unit: An Observational Study. Cureus 2018; 10:e3716. [PMID: 30906677 PMCID: PMC6428362 DOI: 10.7759/cureus.3716] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/05/2018] [Accepted: 12/11/2018] [Indexed: 11/09/2022] Open
Abstract
Measuring and monitoring cerebral perfusion pressure (CPP) is important in the management of patients with certain neurological conditions. To accurately reflect blood pressure at the circle of Willis, the arterial line transducer should be leveled at the tragus. This study measured the relative distance of the transducer to the tragus in 100 intensive care unit (ICU) patients in the mixed ICU at our institution, of which 44 patients had a pressure-sensitive neurological diagnosis. For neurological patients, the average distance was 10.9 cm and for non-neurological patients, the average distance was 11.4 cm (p-value: 0.60). This suggests that the arterial line transducer was leveled at approximately the same level regardless of pathology, potentially leading to falsely elevated CPP readings in patients with pressure-sensitive neurological pathology.
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Affiliation(s)
- Brian Tse
- Anesthesiology, Stanford University Medical Center, Stanford, USA
| | - Mark A Burbridge
- Anesthesiology, Stanford University Medical Center, Stanford, USA
| | - Richard A Jaffe
- Anesthesiology, Stanford University Medical Center, Stanford, USA
| | - John Brock-Utne
- Anesthesiology, Stanford University Medical Center, Stanford, USA
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Sanz-García A, Pérez-Romero M, Pastor J, Sola RG, Vega-Zelaya L, Monasterio F, Torrecilla C, Vega G, Pulido P, Ortega GJ. Identifying causal relationships between EEG activity and intracranial pressure changes in neurocritical care patients. J Neural Eng 2018; 15:066029. [PMID: 30181428 DOI: 10.1088/1741-2552/aadeea] [Citation(s) in RCA: 18] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE To explore and assess the relationship between electroencephalography (EEG) activity and intracranial pressure (ICP) in patients suffering from traumatic brain injury (TBI) and subarachnoid hemorrhage (SAH) during their stay in an intensive care unit. APPROACH We performed an observational prospective cohort study of adult patients suffering from TBI or SAH. Continuous EEG-ECG was performed during ICP monitoring. In every patient, variables derived from the EEG were calculated and the Granger causality (GC) methodology was employed to assess whether, and in which direction, there is any relationship between EEG and ICP. MAIN RESULTS One-thousand fifty-five hours of continuous multimodal monitoring were analyzed in 21 patients using the GC test. During 37.88% of the analyzed time, significant GC statistic was found in the direction from the EEG activity to the ICP, with typical lags of 25-50 s between them. When recordings were adjusted by sedation-perfusion and/or bolus-and handling, these percentages hardly changed. SIGNIFICANCE Long-lasting, continuous and simultaneous EEG and ICP recordings from TBI and SAH patients provide highly rich and useful information, which has allowed for uncovering a strong relationship between both signals. The use of this relationship could lead to developing a medical device to measure ICP in a non-invasive way.
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Affiliation(s)
- Ancor Sanz-García
- Instituto de Investigación Sanitaria, Hospital de la Princesa, Madrid, Spain
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El-Bouri WK, Vignali D, Iliadi K, Bulters D, Marchbanks RJ, Birch AA, Simpson DM. Quantifying the contribution of intracranial pressure and arterial blood pressure to spontaneous tympanic membrane displacement. Physiol Meas 2018; 39:085002. [PMID: 29999499 DOI: 10.1088/1361-6579/aad308] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
OBJECTIVE Although previous studies have shown associations between patient symptoms/outcomes and the spontaneous tympanic membrane displacement (spTMD) pulse amplitude, the contribution of the underlying intracranial pressure (ICP) signal to the spTMD pulse remains largely unknown. We have assessed the relative contributions of ICP and arterial blood pressure (ABP) on spTMD at different frequencies in order to determine whether spTMD contains information about the ICP above and beyond that contained in the ABP. APPROACH Eleven patients, who all had invasive ICP and ABP measurements in situ, were recruited from our intensive care unit. Their spTMD was recorded and the power spectral densities of the three signals, as well as coherences between the signals, were calculated in the range 0.1-5 Hz. Simple and multiple coherences, coupled with statistical tests using surrogate data, were carried out to quantify the relative contributions of ABP and ICP to spTMD. MAIN RESULTS Most power of the signals was found to predominate at respiration rate, heart rate, and their harmonics, with little outside of these frequencies. Analysis of the simple coherences found a slight preference for ICP transmission, beyond that from ABP, to the spTMD at lower frequencies (7/11 patients at respiration, 7/10 patients at respiration 1st harmonic) which is reversed at the higher frequencies (2/11 patients at heart rate and its 1st harmonic). Both ICP and ABP were found to independently contribute to the spTMD. The multiple coherence reinforced that ICP is preferentially being transmitted at respiration and respiration 1st harmonic. SIGNIFICANCE Both ABP and ICP contribute independently to the spTMD signal, with most power occurring at clear physiological frequencies-respiration and harmonics and heart rate and harmonics. There is information shared between the ICP and spTMD that is not present in ABP. This analysis has indicated that lower frequencies appear to favour ICP as the driver for spTMD.
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Affiliation(s)
- Wahbi K El-Bouri
- Neurological Physics Group, Department of Medical Physics, University Hospital Southampton NHS Foundation Trust, Southampton, United Kingdom. Institute for Sound and Vibration Research, University of Southampton, Southampton, United Kingdom
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Abstract
Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.
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Klein SP, Bruyninckx D, Callebaut I, Depreitere B. Comparison of Intracranial Pressure and Pressure Reactivity Index Obtained Through Pressure Measurements in the Ventricle and in the Parenchyma During and Outside Cerebrospinal Fluid Drainage Episodes in a Manipulation-Free Patient Setting. ACTA NEUROCHIRURGICA. SUPPLEMENT 2018; 126:287-290. [PMID: 29492576 DOI: 10.1007/978-3-319-65798-1_56] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
OBJECTIVE We investigated the effect of cerebrospinal fluid (CSF) drainage on the intracranial pressure (ICP) signal measured in the parenchyma and the ventricle as well as the effect on the pressure reactivity index (PRx) calculated from both signals. METHODS Ten patients were included in this prospective study. All patients received a parenchymal ICP sensor and an external ventricular drain (EVD) for CSF drainage. ICP signals (ICP-p and ICP-evd) were captured. Part of the study was a period of 90 min during which the patient was free from any manipulation, consisting of 30 min of drainage (O1), 30 min EVD closed (C) and 30 min of drainage (O2). RESULTS Mean ICP-evd and mean AMP-evd increased (3.03 and 0.46 mmHg) from O1 to C and decreased (2.12 and 0.43 mmHg) from C to O2. ICP-p and AMP-p changes were less pronounced (closing EVD: +0.81 mmHg/+0.22 mmHg; opening EVD: -0.22 mmHg/-0.05 mmHg). Mean difference between PRx-evd and PRx-p was 0.12 for O1, 0.02 for C and -0.02 for O2. The intraclass correlation coefficient for absolute agreement of single measures was 0.66 for O1, 0.77 for C and 0.69 for O2. Mean PRx differences demonstrated a significant difference between O1 versus C and O1 versus O2 but not between C versus O2. CONCLUSION Drainage of CSF reduces ICP magnitude and amplitude through the EVD. This effect was only marginal in parenchymal ICP measurements. In manipulation-free circumstances, agreement of PRx obtained through parenchymal and ventricular measurements was moderate to good, depending on the statistical method, and was not necessarily influenced by drainage.
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Affiliation(s)
| | | | - Ina Callebaut
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, University Hospitals Leuven, Leuven, Belgium
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30
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Abstract
Brain injury, such as from stroke and trauma, can be complicated by elevated intracranial pressure (ICP). Although raised ICP can be a significant determinant of morbidity and mortality, clinical studies often report widely varying ICP measurements depending on location of measurement and technique used. For the same reasons, reported ICP measurements also vary widely in animal models. The need for anesthesia or tethered connections with some methods of ICP measurement in animals may introduce additional confounds. Moreover, these methods are not well suited for prolonged, continuous measurement. Here, we describe an approach to continually measure ICP in awake, freely moving rats for several days. This technique uses a commercially available, wireless pressure sensor mounted on the head to measure ICP from the epidural space via a fluid-filled catheter. We have demonstrated that this approach reliably detects elevations in ICP that last for several days after ischemic and hemorrhagic strokes in rat.
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Affiliation(s)
- Michael R Williamson
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Roseleen F John
- Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada
| | - Frederick Colbourne
- Department of Psychology, Neuroscience and Mental Health Institute, University of Alberta, Edmonton, AB, Canada.
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32
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Godoy DA, Videtta W, Di Napoli M. Practical Approach to Posttraumatic Intracranial Hypertension According to Pathophysiologic Reasoning. Neurol Clin 2017; 35:613-640. [DOI: 10.1016/j.ncl.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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33
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Stroehle M, Lederer W, Schmid S, Glodny B, Chemelli AP, Wiedermann FJ. Aortic stent graft placement under extracorporeal membrane oxygenation in severe multiple trauma. Clin Case Rep 2017; 5:1604-1607. [PMID: 29026554 PMCID: PMC5628234 DOI: 10.1002/ccr3.1127] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/01/2017] [Revised: 07/19/2017] [Accepted: 07/24/2017] [Indexed: 12/29/2022] Open
Abstract
Placement of an aortic stent graft under extracorporeal membrane oxygenation was the life‐saving procedure in a case of severe head trauma and traumatic aortic dissection after injured by a railroad engine. Timely access to neurosurgery, heart surgery, and radiology providing minimal invasive interventions increase the chances of a favorable outcome.
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Affiliation(s)
- Mathias Stroehle
- Department of General and Surgical Critical Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Wolfgang Lederer
- Department of Anesthesiology and Critical Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Stefan Schmid
- Department of General and Surgical Critical Care Medicine Medical University of Innsbruck Innsbruck Austria
| | - Bernhard Glodny
- Department of Radiology Medical University of Innsbruck Innsbruck Austria
| | - Andreas P Chemelli
- Department of Radiology Landesklinikum Baden-Mödling Baden-Mödling Austria
| | - Franz J Wiedermann
- Department of Anesthesiology and Critical Care Medicine Medical University of Innsbruck Innsbruck Austria
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34
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Baker WB, Parthasarathy AB, Gannon KP, Kavuri VC, Busch DR, Abramson K, He L, Mesquita RC, Mullen MT, Detre JA, Greenberg JH, Licht DJ, Balu R, Kofke WA, Yodh AG. Noninvasive optical monitoring of critical closing pressure and arteriole compliance in human subjects. J Cereb Blood Flow Metab 2017; 37:2691-2705. [PMID: 28541158 PMCID: PMC5536813 DOI: 10.1177/0271678x17709166] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/09/2023]
Abstract
The critical closing pressure ( CrCP) of the cerebral circulation depends on both tissue intracranial pressure and vasomotor tone. CrCP defines the arterial blood pressure ( ABP) at which cerebral blood flow approaches zero, and their difference ( ABP - CrCP) is an accurate estimate of cerebral perfusion pressure. Here we demonstrate a novel non-invasive technique for continuous monitoring of CrCP at the bedside. The methodology combines optical diffuse correlation spectroscopy (DCS) measurements of pulsatile cerebral blood flow in arterioles with concurrent ABP data during the cardiac cycle. Together, the two waveforms permit calculation of CrCP via the two-compartment Windkessel model for flow in the cerebral arterioles. Measurements of CrCP by optics (DCS) and transcranial Doppler ultrasound (TCD) were carried out in 18 healthy adults; they demonstrated good agreement (R = 0.66, slope = 1.14 ± 0.23) with means of 11.1 ± 5.0 and 13.0 ± 7.5 mmHg, respectively. Additionally, a potentially useful and rarely measured arteriole compliance parameter was derived from the phase difference between ABP and DCS arteriole blood flow waveforms. The measurements provide evidence that DCS signals originate predominantly from arteriole blood flow and are well suited for long-term continuous monitoring of CrCP and assessment of arteriole compliance in the clinic.
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Affiliation(s)
- Wesley B Baker
- 1 Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, USA
| | - Ashwin B Parthasarathy
- 2 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA.,3 Department of Electrical Engineering, University of South Florida, Tampa, USA
| | - Kimberly P Gannon
- 4 Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - Venkaiah C Kavuri
- 2 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA
| | - David R Busch
- 5 Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Kenneth Abramson
- 2 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA
| | - Lian He
- 2 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA
| | | | - Michael T Mullen
- 4 Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - John A Detre
- 4 Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - Joel H Greenberg
- 4 Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - Daniel J Licht
- 5 Division of Neurology, Department of Pediatrics, Children's Hospital of Philadelphia, Philadelphia, USA
| | - Ramani Balu
- 4 Department of Neurology, University of Pennsylvania, Philadelphia, USA
| | - W Andrew Kofke
- 1 Department of Anesthesiology and Critical Care, University of Pennsylvania, Philadelphia, USA
| | - Arjun G Yodh
- 2 Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, USA
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35
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Godoy DA, Seifi A, Garza D, Lubillo-Montenegro S, Murillo-Cabezas F. Hyperventilation Therapy for Control of Posttraumatic Intracranial Hypertension. Front Neurol 2017; 8:250. [PMID: 28769857 PMCID: PMC5511895 DOI: 10.3389/fneur.2017.00250] [Citation(s) in RCA: 56] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/06/2017] [Accepted: 05/19/2017] [Indexed: 12/30/2022] Open
Abstract
During traumatic brain injury, intracranial hypertension (ICH) can become a life-threatening condition if it is not managed quickly and adequately. Physicians use therapeutic hyperventilation to reduce elevated intracranial pressure (ICP) by manipulating autoregulatory functions connected to cerebrovascular CO2 reactivity. Inducing hypocapnia via hyperventilation reduces the partial pressure of arterial carbon dioxide (PaCO2), which incites vasoconstriction in the cerebral resistance arterioles. This constriction decrease cerebral blood flow, which reduces cerebral blood volume and, ultimately, decreases the patient’s ICP. The effects of therapeutic hyperventilation (HV) are transient, but the risks accompanying these changes in cerebral and systemic physiology must be carefully considered before the treatment can be deemed advisable. The most prominent criticism of this approach is the cited possibility of developing cerebral ischemia and tissue hypoxia. While it is true that certain measures, such as cerebral oxygenation monitoring, are needed to mitigate these dangerous conditions, using available evidence of potential poor outcomes associated with HV as justification to dismiss the implementation of therapeutic HV is debatable and remains a controversial subject among physicians. This review highlights various issues surrounding the use of HV as a means of controlling posttraumatic ICH, including indications for treatment, potential risks, and benefits, and a discussion of what techniques can be implemented to avoid adverse complications.
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Affiliation(s)
- Daniel Agustín Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Argentina.,Intensive Care Unit, Hospital San Juan Bautista, Catamarca, Argentina
| | - Ali Seifi
- University of Texas Health Science Center San Antonio, San Antonio, TX, United States
| | - David Garza
- Department of Neurosurgery, University of Texas Health Science Center San Antonio, San Antonio, TX, United States
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36
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Puntis M, Smith M. Critical care management of adult traumatic brain injury. ANAESTHESIA AND INTENSIVE CARE MEDICINE 2017. [DOI: 10.1016/j.mpaic.2017.02.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/25/2023]
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37
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Benefit on optimal cerebral perfusion pressure targeted treatment for traumatic brain injury patients. J Crit Care 2017; 41:49-55. [PMID: 28477510 DOI: 10.1016/j.jcrc.2017.04.029] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/22/2016] [Revised: 04/02/2017] [Accepted: 04/20/2017] [Indexed: 12/17/2022]
Abstract
PURPOSE The maintenance of patient-specific optimal cerebral perfusion pressure (CPPopt) is crucial for patients with traumatic brain injury (TBI). The goal of the study was to explore the influence of CPP declination from CPPopt value on the TBI patients' outcome. METHODS The CPP and cerebrovascular autoregulation (CA) monitoring of 52 TBI patients was performed. Patient-specific CPPopt has been identified and the associations between the patients' outcome and complex influence of time of CPP declination from CPPopt value, age, and the duration of CA impairment episodes has been analyzed. RESULTS The multiple correlation coefficient between the Glasgow outcome scale (GOS), duration of CA impairment events and percentage time, when 0<ΔCPPopt<10mmHg was r=-0.643 (P<0.001). The multiple correlation coefficients between GOS, age, and percentage time of ΔCPPopt when 0<ΔCPPopt<10mmHg was r=-0.587 (P<0.001). CONCLUSION The CPPopt-targeted patient-specific management might be useful for stabilizing CA in TBI patients as well as for improving their outcome. Better outcomes were obtained by maintaining CPP in light hyperperfusion condition (up to 10mmHg above CPPopt) when CPPopt is in the range of 60-80mmHg, and keeping CPP within the range of CPPopt +/-5mmHg when CPPopt is above 80mmHg.
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38
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Abstract
The monitoring of systemic and central nervous system physiology is central to the management of patients with neurologic disease in the perioperative and critical care settings. There exists a range of invasive and noninvasive and global and regional monitors of cerebral hemodynamics, oxygenation, metabolism, and electrophysiology that can be used to guide treatment decisions after acute brain injury. With mounting evidence that a single neuromonitor cannot comprehensively detect all instances of cerebral compromise, multimodal neuromonitoring allows an individualized approach to patient management based on monitored physiologic variables rather than a generic one-size-fits-all approach targeting predetermined and often empirical thresholds.
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39
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García-Lira JR, Zapata-Vázquez RE, Alonzo-Vázquez F, Rodríguez-Ruz SG, Medina-Moreno MR, Torres-Escalante JL. [Monitoring intracranial pressure in severe traumatic brain injury]. REVISTA CHILENA DE PEDIATRIA 2016; 87:387-394. [PMID: 27296717 DOI: 10.1016/j.rchipe.2016.04.006] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 09/28/2015] [Revised: 03/18/2016] [Accepted: 04/18/2016] [Indexed: 10/21/2022]
Abstract
INTRODUCTION Severe traumatic brain injury (TBI) is a serious condition. Intracranial pressure (ICP) monitoring can be used to direct treatment, which is of limited access in developing countries. OBJECTIVE To describe the clinical experience of pediatric patients with severe TBI. PATIENTS AND METHOD A clinical experience in patients with severe TBI was conducted. Age was 1-17 years, exclusion criteria were chronic illness and psicomotor retardation. Informed consent was obtained in each case. Two groups were formed based on the criterion of neurosurgeons: with and without intracraneal pressure (ICP) monitoring. PIC monitoring was performed through a 3PN Spiegelberg catheter and a Spiegelberg HDM 26 monitor. Patients were treated according international pediatric guides. The characteristics of both groups are described at 6 months of follow-up. RESULTS Forty-two patients (CM=14 and SM=28). Those in the CM Group had lower Glasgow coma scale score and Marshall classification with poorer prognosis. Among them survival rate was lower, although the outcome was from moderate to good. No complications were reported with the use of the ICP catheter. CONCLUSION Patients with ICP monitoring had greater severity at admission and an increased mortality; however, the outcome for the survivors was from moderate to good. It is necessary to conduct randomized clinical trials to define the impact of ICP monitoring on survival and quality of life in severe TBI patients.
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Affiliation(s)
| | - Rita Esther Zapata-Vázquez
- Unidad Interinstitucional de Investigación Clínica y Epidemiológica, Facultad de Medicina, Universidad Autónoma de Yucatán, Mérida, Yucatán, México
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40
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Lv O, Zhou F, Zheng Y, Li Q, Wang J, Zhu Y. Mild hypothermia protects against early brain injury in rats following subarachnoid hemorrhage via the TrkB/ERK/CREB signaling pathway. Mol Med Rep 2016; 14:3901-7. [PMID: 27600366 DOI: 10.3892/mmr.2016.5709] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2015] [Accepted: 08/18/2016] [Indexed: 11/06/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a severe neurological disease, which is associated with a significant number of cases of premature mortality and disability worldwide. Mild hypothermia (MH) has been proposed as a potential therapeutic strategy to reduce neuronal injury following SAH. The present study aimed to investigate the mechanisms of MH's protective role in the process of SAH. The present study demonstrated that MH was able to protect against early brain injury in a rat model of SAH. Treating SAH rats with MH reduced the release of reactive oxygen species and prevented activation of apoptotic cascades. Furthermore, the protective effects of MH were shown to be mediated by enhanced activity of the tropomyosin receptor kinase B/extracellular signal‑regulated kinases/cAMP response element binding protein (TrkB/ERK/CREB) pathway. Inhibition of TrkB/ERK/CREB activity using a small molecule inhibitor largely abolished the beneficial effects of MH in SAH rats. These results outline an endogenous mechanism underlying the neuroprotective effects of MH in SAH.
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Affiliation(s)
- Ou Lv
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, P.R. China
| | - Fenggang Zhou
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, P.R. China
| | - Yongri Zheng
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, P.R. China
| | - Qingsong Li
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, P.R. China
| | - Jianjiao Wang
- Department of Neurosurgery, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, P.R. China
| | - Yulan Zhu
- Department of Neurology, The Second Affiliated Hospital of Harbin Medical University, Harbin, Heilongjiang 150086, P.R. China
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41
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Abstract
A mismatch between cerebral oxygen supply and demand can lead to cerebral hypoxia/ischemia and deleterious outcomes. Cerebral oxygenation monitoring is an important aspect of multimodality neuromonitoring. It is increasingly deployed whenever intracranial pressure monitoring is indicated. Although there is a large body of evidence demonstrating an association between cerebral hypoxia/ischemia and poor outcomes, it remains to be determined whether restoring cerebral oxygenation leads to improved outcomes. Randomized prospective studies are required to address uncertainties about cerebral oxygenation monitoring and management. This article describes the different methods of monitoring cerebral oxygenation, their indications, evidence base, limitations, and future perspectives.
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Affiliation(s)
- Matthew A Kirkman
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK
| | - Martin Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK.
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Wilson MH. Monro-Kellie 2.0: The dynamic vascular and venous pathophysiological components of intracranial pressure. J Cereb Blood Flow Metab 2016; 36:1338-50. [PMID: 27174995 PMCID: PMC4971608 DOI: 10.1177/0271678x16648711] [Citation(s) in RCA: 172] [Impact Index Per Article: 21.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/03/2016] [Revised: 04/05/2016] [Accepted: 04/17/2016] [Indexed: 12/16/2022]
Abstract
For 200 years, the 'closed box' analogy of intracranial pressure (ICP) has underpinned neurosurgery and neuro-critical care. Cushing conceptualised the Monro-Kellie doctrine stating that a change in blood, brain or CSF volume resulted in reciprocal changes in one or both of the other two. When not possible, attempts to increase a volume further increase ICP. On this doctrine's "truth or relative untruth" depends many of the critical procedures in the surgery of the central nervous system. However, each volume component may not deserve the equal weighting this static concept implies. The slow production of CSF (0.35 ml/min) is dwarfed by the dynamic blood in and outflow (∼700 ml/min). Neuro-critical care practice focusing on arterial and ICP regulation has been questioned. Failure of venous efferent flow to precisely match arterial afferent flow will yield immediate and dramatic changes in intracranial blood volume and pressure. Interpreting ICP without interrogating its core drivers may be misleading. Multiple clinical conditions and the cerebral effects of altitude and microgravity relate to imbalances in this dynamic rather than ICP per se. This article reviews the Monro-Kellie doctrine, categorises venous outflow limitation conditions, relates physiological mechanisms to clinical conditions and suggests specific management options.
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Affiliation(s)
- Mark H Wilson
- Institute of Pre-Hospital Care, London's Air Ambulance, The Royal London Hospital, Queen Mary College, London, UK
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43
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Dillon DJ, Dougan N. Simultaneous measurement of mean arterial pressure with reference to both the phlebostatic axis and middle cranial fossa in the calculation of cerebral perfusion pressure. Br J Anaesth 2016; 117:268-9. [PMID: 27440648 DOI: 10.1093/bja/aew206] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
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44
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Tamosuitis T, Pranskunas A, Balciuniene N, Pilvinis V, Boerma EC. Conjunctival microcirculatory blood flow is altered but not abolished in brain dead patients: a prospective observational study. BMC Neurol 2016; 16:95. [PMID: 27401581 PMCID: PMC4939832 DOI: 10.1186/s12883-016-0618-z] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2015] [Accepted: 06/09/2016] [Indexed: 12/29/2022] Open
Abstract
Background The conjunctival microcirculation has potential as a window to cerebral perfusion due to related blood supply, close anatomical proximity and easy accessibility for microcirculatory imaging technique, such as sidestream dark field (SDF) imaging. Our study aims to evaluate conjunctival and sublingual microcirculation in brain dead patients and to compare it with healthy volunteers in two diametrically opposed conditions: full stop versus normal arterial blood supply to the brain. Methods In a prospective observational study we analyzed conjunctival and sublingual microcirculation using SDF imaging in brain dead patients after reaching systemic hemodynamic targets to optimize perfusion of donor organs, and in healthy volunteers. All brain death diagnoses were confirmed by cerebral angiography. Microcirculatory images were obtained and analyzed using standardized published recommendations. Study registered at ClinicalTrials.gov, number NCT02483273. Results Eleven brain dead patients and eleven apparently healthy controls were enrolled in the study. Microvascular flow index (MFI) of small vessels was significantly lower in brain dead patients in comparison to healthy controls in ocular conjunctiva (2.7 [2.4–2.9] vs. 3.0 [2.9–3.0], p = 0.01) and in sublingual mucosa (2.8 [2.6–2.9] vs. 3.0 [2.9–3.0], p = 0.02). Total vessel density (TVD) and perfused vessel density (PVD) of small vessels were significantly lower in brain dead patients in comparison to healthy controls in ocular conjunctiva (10.2 [6.6–14.8] vs. 18.0 [18.0–25.4] mm/mm2, p = 0.001 and 5.0 [3.5–7.3] vs. 10.9 [10.9–13.5] 1/mm, p = 0.001), but not in sublingual mucosa. Conclusion In comparison to healthy controls brain dead patients had a significant reduction in conjunctival microvascular blood flow and density. However, the presence of conjunctival flow in case general cerebral flow is completely absent makes it impossible to use the conjunctival microcirculation as a substitute for brain flow, and further research should focus on the link between the ocular microcirculation, intracranial pressure and alternative ocular circulation.
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Affiliation(s)
- Tomas Tamosuitis
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009, Kaunas, Lithuania
| | - Andrius Pranskunas
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009, Kaunas, Lithuania.
| | - Neringa Balciuniene
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009, Kaunas, Lithuania
| | - Vidas Pilvinis
- Department of Intensive Care Medicine, Lithuanian University of Health Sciences, Eiveniu str. 2, LT-50009, Kaunas, Lithuania
| | - E Christiaan Boerma
- Department of Intensive Care Medicine, Medical Center Leeuwarden, Henri Dunantweg 2, Leeuwarden, 8901 BR, The Netherlands.,Department of Translational Physiology, Academic Medical Center, Amsterdam, The Netherlands
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Abstract
Investigators from University of Melbourne, Australia, studied Pressure-Reactivity Index (PRx) and optimal Cerebral Perfusion Pressure (CPP) in 36 children aged between 6 months and 16 years treated for traumatic brain injury (TBI) at the Royal Children's Hospital, Melbourne, from 2007 to 2013.
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Affiliation(s)
- Laurence Ducharme-Crevier
- Ruth D. & Ken M. Davee Pediatric Neurocritical Care Program, Ann & Robert H. Lurie Children's Hospital of Chicago, Chicago, IL; Departments of Pediatrics and Neurology, Northwestern University Feinberg School of Medicine, Chicago, IL
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46
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Tamm AS, McCourt R, Gould B, Kate M, Kosior JC, Jeerakathil T, Gioia LC, Dowlatshahi D, Hill MD, Coutts SB, Demchuk AM, Buck BH, Emery DJ, Shuaib A, Butcher KS. Cerebral Perfusion Pressure is Maintained in Acute Intracerebral Hemorrhage: A CT Perfusion Study. AJNR Am J Neuroradiol 2016; 37:244-51. [PMID: 26450534 PMCID: PMC7959964 DOI: 10.3174/ajnr.a4532] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2015] [Accepted: 07/14/2015] [Indexed: 02/03/2023]
Abstract
BACKGROUND AND PURPOSE Although blood pressure reduction has been postulated to result in a fall in cerebral perfusion pressure in patients with intracerebral hemorrhage, the latter is rarely measured. We assessed regional cerebral perfusion pressure in patients with intracerebral hemorrhage by using CT perfusion source data. MATERIALS AND METHODS Patients with acute primary intracerebral hemorrhage were randomized to target systolic blood pressures of <150 mm Hg (n = 37) or <180 mm Hg (n = 36). Regional maps of cerebral blood flow, cerebral perfusion pressure, and cerebrovascular resistance were generated by using CT perfusion source data, obtained 2 hours after randomization. RESULTS Perihematoma cerebral blood flow (38.7 ± 11.9 mL/100 g/min) was reduced relative to contralateral regions (44.1 ± 11.1 mL/100 g/min, P = .001), but cerebral perfusion pressure was not (14.4 ± 4.6 minutes(-1) versus 14.3 ± 4.8 minutes(-1), P = .93). Perihematoma cerebrovascular resistance (0.34 ± 0.11 g/mL) was higher than that in the contralateral region (0.30 ± 0.10 g/mL, P < .001). Ipsilateral and contralateral cerebral perfusion pressure in the external (15.0 ± 4.6 versus 15.6 ± 5.3 minutes(-1), P = .15) and internal (15.0 ± 4.8 versus 15.0 ± 4.8 minutes(-1), P = .90) borderzone regions were all similar. Borderzone cerebral perfusion pressure was similar to mean global cerebral perfusion pressure (14.7 ± 4.7 minutes(-1), P ≥ .29). Perihematoma cerebral perfusion pressure did not differ between blood pressure treatment groups (13.9 ± 5.5 minutes(-1) versus 14.8 ± 3.4 minutes(-1), P = .38) or vary with mean arterial pressure (r = -0.08, [-0.10, 0.05]). CONCLUSIONS Perihematoma cerebral perfusion pressure is maintained despite increased cerebrovascular resistance and reduced cerebral blood flow. Aggressive antihypertensive therapy does not affect perihematoma or borderzone cerebral perfusion pressure. Maintenance of cerebral perfusion pressure provides physiologic support for the safety of blood pressure reduction in intracerebral hemorrhage.
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Affiliation(s)
- A S Tamm
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - R McCourt
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - B Gould
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - M Kate
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - J C Kosior
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - T Jeerakathil
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - L C Gioia
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D Dowlatshahi
- Division of Neurology (D.D.), University of Ottawa, Ottawa, Ontario, Canada
| | - M D Hill
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - S B Coutts
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - A M Demchuk
- Department of Clinical Neurosciences (M.D.H., S.B.C., A.M.D.), University of Calgary, Calgary, Alberta, Canada
| | - B H Buck
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - D J Emery
- Department of Diagnostic Imaging (A.S.T., D.J.E.), University of Alberta, Edmonton, Alberta, Canada
| | - A Shuaib
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
| | - K S Butcher
- From the Division of Neurology (R.M., B.G., M.K., J.C.K., T.J., L.C.G., B.H.B., A.S., K.S.B.)
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47
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Abstract
Advances in technology have resulted in a plethora of invasive neuromonitoring options for practitioners to manage while caring for the complex needs of the critical care patient. Although many types of invasive neuromonitoring are available to the practitioner, intraparenchymal monitors and external ventricular devices are used most frequently in the clinical setting and are the focus of this article. In addition, multimodality monitoring has been noted to confer a survival benefit in patients with this complex type of invasive neuromonitoring and is discussed as well.
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Affiliation(s)
- Carey Heck
- College of Nursing, Thomas Jefferson University, 901 Walnut Street, Suite 815, Philadelphia, PA 19107, USA.
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48
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Advances in Intracranial Pressure Monitoring and Its Significance in Managing Traumatic Brain Injury. Int J Mol Sci 2015; 16:28979-97. [PMID: 26690122 PMCID: PMC4691093 DOI: 10.3390/ijms161226146] [Citation(s) in RCA: 73] [Impact Index Per Article: 8.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2015] [Revised: 11/24/2015] [Accepted: 11/24/2015] [Indexed: 12/11/2022] Open
Abstract
Intracranial pressure (ICP) measurements are essential in evaluation and treatment of neurological disorders such as subarachnoid and intracerebral hemorrhage, ischemic stroke, hydrocephalus, meningitis/encephalitis, and traumatic brain injury (TBI). The techniques of ICP monitoring have evolved from invasive to non-invasive-with both limitations and advantages. Some limitations of the invasive methods include short-term monitoring, risk of infection, restricted mobility of the subject, etc. The invasiveness of a method limits the frequency of ICP evaluation in neurological conditions like hydrocephalus, thus hampering the long-term care of patients with compromised ICP. Thus, there has been substantial interest in developing noninvasive techniques for assessment of ICP. Several approaches were reported, although none seem to provide a complete solution due to inaccuracy. ICP measurements are fundamental for immediate care of TBI patients in the acute stages of severe TBI injury. In severe TBI, elevated ICP is associated with mortality or poor clinical outcome. ICP monitoring in conjunction with other neurological monitoring can aid in understanding the pathophysiology of brain damage. This review article presents: (a) the significance of ICP monitoring; (b) ICP monitoring methods (invasive and non-invasive); and (c) the role of ICP monitoring in the management of brain damage, especially TBI.
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49
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McNett M, Koren J. Blood Pressure Management Controversies in Neurocritical Care. Crit Care Nurs Clin North Am 2015; 28:9-19. [PMID: 26873756 DOI: 10.1016/j.cnc.2015.09.002] [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: 11/16/2022]
Abstract
Blood pressure (BP) management is essential in neurocritical care settings to ensure adequate cerebral perfusion and prevent secondary brain injury. Despite consensus on the importance of BP monitoring, significant practice variations persist regarding optimal methods for monitoring and treatment of BP values among patients with neurologic injuries. This article provides a summary of research investigating various approaches for BP management in neurocritical care. Evidence-based recommendations, areas for future research, and current technological advancements for BP management are discussed.
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Affiliation(s)
- Molly McNett
- Nursing Research, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Drive, Cleveland, OH 44109, USA.
| | - Jay Koren
- Surgical Intensive Care Unit, The MetroHealth System, Nursing Business Office, 2500 MetroHealth Drive, Cleveland, OH 44109, USA
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50
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Kim N, Krasner A, Kosinski C, Wininger M, Qadri M, Kappus Z, Danish S, Craelius W. Trending autoregulatory indices during treatment for traumatic brain injury. J Clin Monit Comput 2015; 30:821-831. [PMID: 26446002 DOI: 10.1007/s10877-015-9779-3] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/26/2015] [Accepted: 09/22/2015] [Indexed: 12/14/2022]
Abstract
Our goal is to use automatic data monitoring for reliable prediction of episodes of intracranial hypertension in patients with traumatic brain injury. Here we test the validity of our method on retrospective patient data. We developed the Continuous Hemodynamic Autoregulatory Monitor (CHARM), that siphons and stores signals from existing monitors in the surgical intensive care unit (SICU), efficiently compresses them, and standardizes the search for statistical relationships between any proposed index and adverse events. CHARM uses an automated event detector to reliably locate episodes of elevated intracranial pressure (ICP), while eliminating artifacts within retrospective patient data. A graphical user interface allowed data scanning, selection of criteria for events, and calculating indices. The pressure reactivity index (PRx), defined as the least square linear regression slope of intracranial pressure versus arterial BP, was calculated for a single case that spanned 259 h. CHARM collected continuous records of ABP, ICP, ECG, SpO2, and ventilation from 29 patients with TBI over an 18-month period. Analysis of a single patient showed that PRx data distribution in the single hours immediately prior to all 16 intracranial hypertensive events, significantly differed from that in the 243 h that did not precede such events (p < 0.0001). The PRx index, however, lacked sufficient resolution as a real-time predictor of IH in this patient. CHARM streamlines the search for reliable predictors of intracranial hypertension. We report statistical evidence supporting the predictive potential of the pressure reactivity index.
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Affiliation(s)
- Nam Kim
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Alex Krasner
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Colin Kosinski
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Michael Wininger
- Rehabilitation Sciences, University of Hartford, West Hartford, CT, 06117, USA
| | - Maria Qadri
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Zachary Kappus
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA
| | - Shabbar Danish
- Department of Neurosurgery, Rutgers Cancer Institute, Rutgers-RWJ Medical School, New Brunswick, NJ, 08901, USA
| | - William Craelius
- Department of Biomedical Engineering, Rutgers, The State University of New Jersey, Piscataway, NJ, 08854, USA.
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