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Mishra RK, Bindra A, Khandelwal A, Sharma D, Goyal K, Rath GP, Gupta DK. Brain Regional Energy Metabolism in Patients with Traumatic Brain Injury: A Cerebral Microdialysis Guided Study. Neurol India 2024; 72:78-82. [PMID: 38443006 DOI: 10.4103/neuroindia.ni_37_21] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/29/2021] [Accepted: 08/21/2021] [Indexed: 03/07/2024]
Abstract
BACKGROUND In traumatic brain injuries (TBI), cerebral microdialysis (CMD)-derived parameters, especially the lactate to pyruvate ratio (LP ratio), have been utilized for cerebral perfusion optimization. The objectives were to identify cerebral ischemia as measured by CMD in TBI patients requiring decompressive craniectomy and to observe the correlation between cerebral perfusion pressure (CPP), intracranial pressure (ICP), and CMD variables in these patients. Our secondary aim was to observe the effect of CPP augmentation on ischemia biomarkers. METHODS After the Institute Ethics Committee approvals, seven adult patients requiring decompressive craniectomy following TBI were enrolled and CMD data were obtained prospectively for 72 h. CPP was augmented by 20% with noradrenaline infusion if LP ratio >40. Correlations were done with bootstrapping (n = 500) to obtain the confidence intervals (CI) due to the small sample size. RESULTS One patient had cerebral ischemia (median LP ratio of 265.5 and median pyruvate of 38 μmol/L), while another patient had non-ischemic mitochondrial dysfunction (median LP ratio 40.7 and median pyruvate 278.5). The coefficients of correlation between the LP ratio with CPP and ICP were r = -0.05 (CI = -0.14-0.03) and r = 0.09 (CI = -0.03-0.24), respectively. The coefficient of correlation between cerebral and blood glucose was r = 0.38, (CI - 0.35-0.14). Only two patients needed CPP augmentation, however, postaugmentation cerebral biochemistry did not change appreciably. CONCLUSION CMD can identify cerebral ischemia, however, no correlations were observed between the LP ratio and CPP or ICP. CPP augmentation did not improve cerebral biochemistry. More studies are required to understand and treat cerebral metabolism in TBI.
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Affiliation(s)
- Rajeeb K Mishra
- Department of Neuroanesthesia and Neurocritical Care, National Institute of Mental Health and Neuro Sciences, Bengaluru, Karnataka, India
| | - Ashish Bindra
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Ankur Khandelwal
- Department of Anesthesiology and Critical Care, Sharda University School of Medical Sciences and Research, Greater Noida, Uttar Pradesh, India
| | - Devjyoti Sharma
- Department of Anesthesiology, Guwahati Neurological Research Centre, Guwahati, Assam, India
| | - Keshav Goyal
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Girija P Rath
- Department of Neuroanesthesiology and Critical Care, All India Institute of Medical Sciences, New Delhi, India
| | - Deepak K Gupta
- Department of Neurosurgery, All India Institute of Medical Sciences, New Delhi, India
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Payen JF, Launey Y, Chabanne R, Gay S, Francony G, Gergele L, Vega E, Montcriol A, Couret D, Cottenceau V, Pili-Floury S, Gakuba C, Hammad E, Audibert G, Pottecher J, Dahyot-Fizelier C, Abdennour L, Gauss T, Richard M, Vilotitch A, Bosson JL, Bouzat P. Intracranial pressure monitoring with and without brain tissue oxygen pressure monitoring for severe traumatic brain injury in France (OXY-TC): an open-label, randomised controlled superiority trial. Lancet Neurol 2023; 22:1005-1014. [PMID: 37863590 DOI: 10.1016/s1474-4422(23)00290-9] [Citation(s) in RCA: 17] [Impact Index Per Article: 17.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Revised: 07/21/2023] [Accepted: 07/26/2023] [Indexed: 10/22/2023]
Abstract
BACKGROUND Optimisation of brain oxygenation might improve neurological outcome after traumatic brain injury. The OXY-TC trial explored the superiority of a strategy combining intracranial pressure and brain tissue oxygen pressure (PbtO2) monitoring over a strategy of intracranial pressure monitoring only to reduce the proportion of patients with poor neurological outcome at 6 months. METHODS We did an open-label, randomised controlled superiority trial at 25 French tertiary referral centres. Within 16 h of brain injury, patients with severe traumatic brain injury (aged 18-75 years) were randomly assigned via a website to be managed during the first 5 days of admission to the intensive care unit either by intracranial pressure monitoring only or by both intracranial pressure and PbtO2 monitoring. Randomisation was stratified by age and centre. The study was open label due to the visibility of the intervention, but the statisticians and outcome assessors were masked to group allocation. The therapeutic objectives were to maintain intracranial pressure of 20 mm Hg or lower, and to keep PbtO2 (for those in the dual-monitoring group) above 20 mm Hg, at all times. The primary outcome was the proportion of patients with an extended Glasgow Outcome Scale (GOSE) score of 1-4 (death to upper severe disability) at 6 months after injury. The primary analysis was reported in the modified intention-to-treat population, which comprised all randomly assigned patients except those who withdrew consent or had protocol violations. This trial is registered with ClinicalTrials.gov, NCT02754063, and is completed. FINDINGS Between June 15, 2016, and April 17, 2021, 318 patients were randomly assigned to receive either intracranial pressure monitoring only (n=160) or both intracranial pressure and PbtO2 monitoring (n=158). 27 individuals with protocol violations were not included in the modified intention-to-treat analysis. Thus, the primary outcome was analysed for 144 patients in the intracranial pressure only group and 147 patients in the intracranial pressure and PbtO2 group. Compared with intracranial pressure monitoring only, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with GOSE score 1-4 (51% [95% CI 43-60] in the intracranial pressure monitoring only group vs 52% [43-60] in the intracranial pressure and PbtO2 monitoring group; odds ratio 1·0 [95% CI 0·6-1·7]; p=0·95). Two (1%) of 144 participants in the intracranial pressure only group and 12 (8%) of 147 participants in the intracranial pressure and PbtO2 group had catheter dysfunction (p=0.011). Six patients (4%) in the intracranial pressure and PbtO2 group had an intracrebral haematoma related to the catheter, compared with none in the intracranial pressure only group (p=0.030). No significant difference in deaths was found between the two groups at 12 months after injury. At 12 months, 33 deaths had occurred in the intracranial pressure group: 25 (76%) were attributable to the brain trauma, six (18%) were end-of-life decisions, and two (6%) due to sepsis. 34 deaths had occured in the intracranial pressure and PbtO2 group at 12 months: 25 (74%) were attributable to the brain trauma, six (18%) were end-of-life decisions, one (3%) due to pulmonary embolism, one (3%) due to haemorrhagic shock, and one (3%) due to cardiac arrest. INTERPRETATION After severe non-penetrating traumatic brain injury, intracranial pressure and PbtO2 monitoring did not reduce the proportion of patients with poor neurological outcome at 6 months. Technical failures related to intracerebral catheter and intracerebral haematoma were more frequent in the intracranial pressure and PbtO2 group. Further research is needed to assess whether a targeted approach to multimodal brain monitoring could be useful in subgroups of patients with severe traumatic brain injury-eg, those with high intracranial pressure on admission. FUNDING The French National Program for Clinical Research, La Fondation des Gueules Cassées, and Integra Lifesciences.
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Affiliation(s)
- Jean-François Payen
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France.
| | - Yoann Launey
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Rennes, Rennes, France
| | - Russell Chabanne
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Clermont-Ferrand, Clermont-Ferrand, France
| | - Samuel Gay
- Department of Intensive Care, Centre Hospitalier Annecy Genevois, Annecy, France
| | - Gilles Francony
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Laurent Gergele
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Saint-Etienne, Saint-Etienne, France
| | - Emmanuel Vega
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Lille, Lille, France
| | - Ambroise Montcriol
- Department of Intensive Care, Hopital Instruction des Armées Saint-Anne, Toulon, France
| | - David Couret
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Sud, Reunion, France
| | - Vincent Cottenceau
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Bordeaux, Bordeaux, France
| | - Sebastien Pili-Floury
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Besançon, Besançon, France
| | - Clement Gakuba
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Caen Normandie, Caen, France
| | - Emmanuelle Hammad
- Department of Anaesthesia and Intensive Care, Hôpital Nord, Assistance Publique des Hopitaux de Marseille, Marseille, France
| | - Gerard Audibert
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Nancy, Nancy, France
| | - Julien Pottecher
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Strasbourg, Strasbourg, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Poitiers, Poitiers, France
| | - Lamine Abdennour
- Department of Anaesthesia and Intensive Care, Hôpital Pitie-Salpetriere, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Tobias Gauss
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Marion Richard
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
| | - Antoine Vilotitch
- Department of Public Health, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
| | - Jean-Luc Bosson
- Department of Public Health, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France
| | - Pierre Bouzat
- Department of Anaesthesia and Intensive Care, Centre Hospitalier Universitaire Grenoble, Universitaire Grenoble Alpes, Grenoble, France; INSERM U1216, Grenoble Institut Neurosciences, Grenoble, France
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Falcone JA, Chen JW. Technical notes on the placement of cerebral microdialysis: A single center experience. Front Neurol 2023; 13:1041952. [PMID: 36698903 PMCID: PMC9868911 DOI: 10.3389/fneur.2022.1041952] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/21/2022] [Indexed: 01/12/2023] Open
Abstract
Background Cerebral microdialysis enables monitoring of brain metabolism and can be an important part of multimodal monitoring strategies in a variety of brain injuries. Microdialysis catheters can be placed in brain parenchyma through a burr hole, a cranial bolt, or directly at the time of an open craniotomy or craniectomy. The location of catheters in relation to brain pathology is important to the interpretation of data and guidance of interventions. Methods Here we retrospectively review the use of cerebral microdialysis at a US Regional Medical Center between March 2018 and February 2022 and provide detailed descriptions and technical nuances of the different methods to place microdialysis catheters. Results Eighty two unique microdialysis catheters were utilized in 52 patients. 35 (42.68%) were placed via a quad-lumen bolt and 47 (57.32%) were placed through craniotomies. 27 catheters (32.93%) were placed in a perilesional location, 50 (60.98%) were located in healthy tissue, and 6 (7.32%) were mispositioned. No significant difference was seen between placement by bolt or craniotomy in regard to perilesional location, mispositioning, or complications. Conclusion With careful planning and thoughtful execution, cerebral microdialysis catheters can be successfully placed though a variety of strategies to optimize and individualize brain monitoring in different clinical settings. This paper provides a detailed guide for the various methods of catheter placement to help providers begin or expand their use of cerebral microdialysis.
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Neurotrauma and Intracranial Pressure Management. Crit Care Clin 2023; 39:103-121. [DOI: 10.1016/j.ccc.2022.08.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022]
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Neurotrauma. Curr Opin Crit Care 2022; 28:715-724. [PMID: 36302199 DOI: 10.1097/mcc.0000000000001005] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
PURPOSE OF REVIEW This review will highlight the latest research relevant to the clinical care of traumatic brain injury (TBI) patients over the last 2 years while underscoring the implications of these advances in the understanding of diagnosis, treatment, and prognosis of TBI. RECENT FINDINGS Brain tissue oxygenation monitoring can identify hypoperfusion as an adjunct to intracerebral pressure monitoring. Multiple biomarker assays are now available to help clinicians screen for mild TBI and biomarker elevations correlate with the size of intracranial injury. Beta-blocker exposure following TBI has demonstrated a survival benefit in those with TBI though the mechanism for this remains unknown. The optimal timing for venous thromboembolism prophylaxis for TBI patients is still uncertain. SUMMARY The current characterization of TBI as mild, moderate, or severe fails to capture the complexity of the disease process and helps little with prognostication. Molecular biomarkers and invasive monitoring devices including brain tissue oxygenation and measures of cerebral autoregulation are being utilized more commonly and can help guide therapy. Extracranial complications following TBI are common and include infection, respiratory failure, coagulopathy, hypercoagulability, and paroxysmal sympathetic hyperactivity.
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Casault C, Couillard P, Kromm J, Rosenthal E, Kramer A, Brindley P. Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners. J Intensive Care Soc 2022; 23:191-202. [PMID: 35615230 PMCID: PMC9125434 DOI: 10.1177/1751143720980273] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Traumatic brain injury (TBI) is common and potentially devastating. Traditional examination-based patient monitoring following TBI may be inadequate for frontline clinicians to reduce secondary brain injury through individualized therapy. Multimodal neurologic monitoring (MMM) offers great potential for detecting early injury and improving outcomes. By assessing cerebral oxygenation, autoregulation and metabolism, clinicians may be able to understand neurophysiology during acute brain injury, and offer therapies better suited to each patient and each stage of injury. Hence, we offer this primer on brain tissue oxygen monitoring, pressure reactivity index monitoring and cerebral microdialysis. This narrative review serves as an introductory guide to the latest clinically-relevant evidence regarding key neuromonitoring techniques.
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Affiliation(s)
- Colin Casault
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
| | - Philippe Couillard
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Julie Kromm
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Eric Rosenthal
- Department of Critical Care
Medicine, University of Alberta, Edmonton, Canada
| | - Andreas Kramer
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Peter Brindley
- Department of Neurology, Harvard
University, Boston, MA, USA
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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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Gargadennec T, Ferraro G, Chapusette R, Chapalain X, Bogossian E, Van Wettere M, Peluso L, Creteur J, Huet O, Sadeghi N, Taccone FS. Detection of cerebral hypoperfusion with a dynamic hyperoxia test using brain oxygenation pressure monitoring. Crit Care 2022; 26:35. [PMID: 35130953 PMCID: PMC8822803 DOI: 10.1186/s13054-022-03918-0] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/29/2022] [Indexed: 11/10/2022] Open
Abstract
Abstract
Introduction
Brain multimodal monitoring including intracranial pressure (ICP) and brain tissue oxygen pressure (PbtO2) is more accurate than ICP alone in detecting cerebral hypoperfusion after traumatic brain injury (TBI). No data are available for the predictive role of a dynamic hyperoxia test in brain-injured patients from diverse etiology.
Aim
To examine the accuracy of ICP, PbtO2 and the oxygen ratio (OxR) in detecting regional cerebral hypoperfusion, assessed using perfusion cerebral computed tomography (CTP) in patients with acute brain injury.
Methods
Single-center study including patients with TBI, subarachnoid hemorrhage (SAH) and intracranial hemorrhage (ICH) undergoing cerebral blood flow (CBF) measurements using CTP, concomitantly to ICP and PbtO2 monitoring. Before CTP, FiO2 was increased directly from baseline to 100% for a period of 20 min under stable conditions to test the PbtO2 catheter, as a standard of care. Cerebral monitoring data were recorded and samples were taken, allowing the measurement of arterial oxygen pressure (PaO2) and PbtO2 at FiO2 100% as well as calculation of OxR (= ΔPbtO2/ΔPaO2). Regional CBF (rCBF) was measured using CTP in the tissue area around intracranial monitoring by an independent radiologist, who was blind to the PbtO2 values. The accuracy of different monitoring tools to predict cerebral hypoperfusion (i.e., CBF < 35 mL/100 g × min) was assessed using area under the receiver-operating characteristic curves (AUCs).
Results
Eighty-seven CTPs were performed in 53 patients (median age 52 [41–63] years—TBI, n = 17; SAH, n = 29; ICH, n = 7). Cerebral hypoperfusion was observed in 56 (64%) CTPs: ICP, PbtO2 and OxR were significantly different between CTP with and without hypoperfusion. Also, rCBF was correlated with ICP (r = − 0.27; p = 0.01), PbtO2 (r = 0.36; p < 0.01) and OxR (r = 0.57; p < 0.01). Compared with ICP alone (AUC = 0.65 [95% CI, 0.53–0.76]), monitoring ICP + PbO2 (AUC = 0.78 [0.68–0.87]) or ICP + PbtO2 + OxR (AUC = 0.80 (0.70–0.91) was significantly more accurate in predicting cerebral hypoperfusion. The accuracy was not significantly different among different etiologies of brain injury.
Conclusions
The combination of ICP and PbtO2 monitoring provides a better detection of cerebral hypoperfusion than ICP alone in patients with acute brain injury. The use of dynamic hyperoxia test could not significantly increase the diagnostic accuracy.
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Optogenetics for Understanding and Treating Brain Injury: Advances in the Field and Future Prospects. Int J Mol Sci 2022; 23:ijms23031800. [PMID: 35163726 PMCID: PMC8836693 DOI: 10.3390/ijms23031800] [Citation(s) in RCA: 4] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/27/2021] [Revised: 01/21/2022] [Accepted: 02/03/2022] [Indexed: 02/07/2023] Open
Abstract
Optogenetics is emerging as an ideal method for controlling cellular activity. It overcomes some notable shortcomings of conventional methods in the elucidation of neural circuits, promotion of neuroregeneration, prevention of cell death and treatment of neurological disorders, although it is not without its own limitations. In this review, we narratively review the latest research on the improvement and existing challenges of optogenetics, with a particular focus on the field of brain injury, aiming at advancing optogenetics in the study of brain injury and collating the issues that remain. Finally, we review the most current examples of research, applying photostimulation in clinical treatment, and we explore the future prospects of these technologies.
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Gouvea Bogossian E, Diaferia D, Ndieugnou Djangang N, Menozzi M, Vincent JL, Talamonti M, Dewitte O, Peluso L, Barrit S, Al Barajraji M, Andre J, Schuind S, Creteur J, Taccone FS. Brain tissue oxygenation guided therapy and outcome in non-traumatic subarachnoid hemorrhage. Sci Rep 2021; 11:16235. [PMID: 34376735 PMCID: PMC8355344 DOI: 10.1038/s41598-021-95602-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023] Open
Abstract
Brain hypoxia can occur after non-traumatic subarachnoid hemorrhage (SAH), even when levels of intracranial pressure (ICP) remain normal. Brain tissue oxygenation (PbtO2) can be measured as a part of a neurological multimodal neuromonitoring. Low PbtO2 has been associated with poor neurologic recovery. There is scarce data on the impact of PbtO2 guided-therapy on patients’ outcome. This single-center cohort study (June 2014–March 2020) included all patients admitted to the ICU after SAH who required multimodal monitoring. Patients with imminent brain death were excluded. Our primary goal was to assess the impact of PbtO2-guided therapy on neurological outcome. Secondary outcome included the association of brain hypoxia with outcome. Of the 163 patients that underwent ICP monitoring, 62 were monitored with PbtO2 and 54 (87%) had at least one episode of brain hypoxia. In patients that required treatment based on neuromonitoring strategies, PbtO2-guided therapy (OR 0.33 [CI 95% 0.12–0.89]) compared to ICP-guided therapy had a protective effect on neurological outcome at 6 months. In this cohort of SAH patients, PbtO2-guided therapy might be associated with improved long-term neurological outcome, only when compared to ICP-guided therapy.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Daniela Diaferia
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Narcisse Ndieugnou Djangang
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Menozzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marta Talamonti
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Olivier Dewitte
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sami Barrit
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mejdeddine Al Barajraji
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Joachim Andre
- Department of Radiology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
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Scarboro M, McQuillan KA. Traumatic Brain Injury Update. AACN Adv Crit Care 2021; 32:29-50. [PMID: 33725106 DOI: 10.4037/aacnacc2021331] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/01/2022]
Abstract
Traumatic brain injury is a devastating, life-changing event in most cases. After the primary brain insult, it is helpful to use evidence-based monitoring techniques to guide implementation of essential interventions to minimize secondary injury and thereby improve patient outcomes. An update on multimodal neuromonitoring is provided in this narrative review, with discussion of tools and techniques currently used in the treatment of patients with brain injury. Neuroprotective treatments, from the well-studied targeted temperature management to new potential therapeutics under investigation, such as glyburide, also are presented.
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Affiliation(s)
- Maureen Scarboro
- Maureen Scarboro is Acute Care Nurse Practitioner, Neurosurgery, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, 22 S Greene St, Baltimore, MD 21201
| | - Karen A McQuillan
- Karen A. McQuillan is Lead Clinical Nurse Specialist, R Adams Cowley Shock Trauma Center, University of Maryland Medical Center, Baltimore, Maryland
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Mismatch between Tissue Partial Oxygen Pressure and Near-Infrared Spectroscopy Neuromonitoring of Tissue Respiration in Acute Brain Trauma: The Rationale for Implementing a Multimodal Monitoring Strategy. Int J Mol Sci 2021; 22:ijms22031122. [PMID: 33498736 PMCID: PMC7865258 DOI: 10.3390/ijms22031122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/21/2022] Open
Abstract
The brain tissue partial oxygen pressure (PbtO2) and near-infrared spectroscopy (NIRS) neuromonitoring are frequently compared in the management of acute moderate and severe traumatic brain injury patients; however, the relationship between their respective output parameters flows from the complex pathogenesis of tissue respiration after brain trauma. NIRS neuromonitoring overcomes certain limitations related to the heterogeneity of the pathology across the brain that cannot be adequately addressed by local-sample invasive neuromonitoring (e.g., PbtO2 neuromonitoring, microdialysis), and it allows clinicians to assess parameters that cannot otherwise be scanned. The anatomical co-registration of an NIRS signal with axial imaging (e.g., computerized tomography scan) enhances the optical signal, which can be changed by the anatomy of the lesions and the significance of the radiological assessment. These arguments led us to conclude that rather than aiming to substitute PbtO2 with tissue saturation, multiple types of NIRS should be included via multimodal systemic- and neuro-monitoring, whose values then are incorporated into biosignatures linked to patient status and prognosis. Discussion on the abnormalities in tissue respiration due to brain trauma and how they affect the PbtO2 and NIRS neuromonitoring is given.
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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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Precision Medicine in Acute Brain Injury: A Narrative Review. J Neurosurg Anesthesiol 2020; 34:e14-e23. [PMID: 32590476 DOI: 10.1097/ana.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/24/2020] [Indexed: 11/26/2022]
Abstract
Over the past few years, the concept of personalized medicine has percolated into the management of different neurological conditions. Improving outcomes after acute brain injury (ABI) continues to be a major challenge. Unrecognized individual multiomic variations in addition to multiple interacting processes may explain why we fail to observe comprehensive improvements in ABI outcomes even when applied treatments appear to be beneficial logically. The provision of clinical care based on a multiomic approach may revolutionize the management of traumatic brain injury, delayed cerebral ischemia after subarachnoid hemorrhage, acute ischemic stroke, and several other neurological diseases. The challenge is to incorporate all the information obtained from genomic studies, other omic data, and individual variability into a practical tool that can be used to assist clinical decision-making. The effective execution of such strategies, which is still far away, requires the development of protocols on the basis of these complex interactions and strict adherence to management protocols. In this review, we will discuss various omics and physiological targets to guide individualized patient management after ABI.
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Alambyan V, Pace J, Sukpornchairak P, Yu X, Alnimir H, Tatton R, Chitturu G, Yarlagadda A, Ramos-Estebanez C. Imaging Guidance for Therapeutic Delivery: The Dawn of Neuroenergetics. Neurotherapeutics 2020; 17:522-538. [PMID: 32240530 PMCID: PMC7283376 DOI: 10.1007/s13311-020-00843-4] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/22/2022] Open
Abstract
Modern neurocritical care relies on ancillary diagnostic testing in the form of multimodal monitoring to address acute changes in the neurological homeostasis. Much of our armamentarium rests upon physiological and biochemical surrogates of organ or regional level metabolic activity, of which a great deal is invested at the metabolic-hemodynamic-hydrodynamic interface to rectify the traditional intermediaries of glucose consumption. Despite best efforts to detect cellular neuroenergetics, current modalities cannot appreciate the intricate coupling between astrocytes and neurons. Invasive monitoring is not without surgical complication, and noninvasive strategies do not provide an adequate spatial or temporal resolution. Without knowledge of the brain's versatile behavior in specific metabolic states (glycolytic vs oxidative), clinical practice would lag behind laboratory empiricism. Noninvasive metabolic imaging represents a new hope in delineating cellular, nigh molecular level energy exchange to guide targeted management in a diverse array of neuropathology.
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Affiliation(s)
- Vilakshan Alambyan
- Department of Neurology, Albert Einstein Medical Center, Philadelphia, Pennsylvania, USA
| | - Jonathan Pace
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Persen Sukpornchairak
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Xin Yu
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Radiology, Case Western Reserve University, Cleveland, Ohio, USA
- Department of Physiology and Biophysics, Case Western Reserve University, Cleveland, Ohio, USA
| | - Hamza Alnimir
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ryan Tatton
- Department of Biomedical Engineering, Case Western Reserve University, Cleveland, Ohio, USA
| | - Gautham Chitturu
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Anisha Yarlagadda
- Department of Arts and Sciences, Case Western Reserve University, Cleveland, Ohio, USA
| | - Ciro Ramos-Estebanez
- Neurological Institute, University Hospitals Cleveland Medical Center, Case Western Reserve University, Cleveland, Ohio, USA.
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Kurtz P, Rocha EEM. Nutrition Therapy, Glucose Control, and Brain Metabolism in Traumatic Brain Injury: A Multimodal Monitoring Approach. Front Neurosci 2020; 14:190. [PMID: 32265626 PMCID: PMC7105880 DOI: 10.3389/fnins.2020.00190] [Citation(s) in RCA: 29] [Impact Index Per Article: 7.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
The goal of neurocritical care in patients with traumatic brain injury (TBI) is to prevent secondary brain damage. Pathophysiological mechanisms lead to loss of body mass, negative nitrogen balance, dysglycemia, and cerebral metabolic dysfunction. All of these complications have been shown to impact outcomes. Therapeutic options are available that prevent or mitigate their negative impact. Nutrition therapy, glucose control, and multimodality monitoring with cerebral microdialysis (CMD) can be applied as an integrated approach to optimize systemic immune and organ function as well as adequate substrate delivery to the brain. CMD allows real-time bedside monitoring of aspects of brain energy metabolism, by measuring specific metabolites in the extracellular fluid of brain tissue. Sequential monitoring of brain glucose and lactate/pyruvate ratio may reveal pathologic processes that lead to imbalances in supply and demand. Early recognition of these patterns may help individualize cerebral perfusion targets and systemic glucose control following TBI. In this direction, recent consensus statements have provided guidelines and recommendations for CMD applications in neurocritical care. In this review, we summarize data from clinical research on patients with severe TBI focused on a multimodal approach to evaluate aspects of nutrition therapy, such as timing and route; aspects of systemic glucose management, such as intensive vs. moderate control; and finally, aspects of cerebral metabolism. Research and clinical applications of CMD to better understand the interplay between substrate supply, glycemic variations, insulin therapy, and their effects on the brain metabolic profile were also reviewed. Novel mechanistic hypotheses in the interpretation of brain biomarkers were also discussed. Finally, we offer an integrated approach that includes nutritional and brain metabolic monitoring to manage severe TBI patients.
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Affiliation(s)
- Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Eduardo E M Rocha
- Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
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Baldassano SN, Hill CE, Shankar A, Bernabei J, Khankhanian P, Litt B. Big data in status epilepticus. Epilepsy Behav 2019; 101:106457. [PMID: 31444029 PMCID: PMC6944751 DOI: 10.1016/j.yebeh.2019.106457] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/30/2019] [Accepted: 07/26/2019] [Indexed: 12/23/2022]
Abstract
Status epilepticus care and treatment are already being touched by the revolution in data science. New approaches designed to leverage the tremendous potential of "big data" in the clinical sphere are enabling researchers and clinicians to extract information from sources such as administrative claims data, the electronic medical health record, and continuous physiologic monitoring data streams. Algorithmic methods of data extraction also offer potential to fuse multimodal data (including text-based documentation, imaging data, and time-series data) to improve patient assessment and stratification beyond the manual capabilities of individual physicians. Still, the potential of data science to impact the diagnosis, treatment, and minute-to-minute care of patients with status epilepticus is only starting to be appreciated. In this brief review, we discuss how data science is impacting the field and draw examples from the following three main areas: (1) analysis of insurance claims from large administrative datasets to evaluate the impact of continuous electroencephalogram (EEG) monitoring on clinical outcomes; (2) natural language processing of the electronic health record to find, classify, and stratify patients for prognostication and treatment; and (3) real-time systems for data analysis, data reduction, and multimodal data fusion to guide therapy in real time. While early, it is our hope that these examples will stimulate investigators to leverage data science, computer science, and engineering methods to improve the care and outcome of patients with status epilepticus and other neurological disorders. This article is part of the Special Issue "Proceedings of the 7th London-Innsbruck Colloquium on Status Epilepticus and Acute Seizures".
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Affiliation(s)
- Steven N. Baldassano
- Department of Bioengineering, University of Pennsylvania, 210 South 33rd Street, Philadelphia, PA 19104, United States,Center for Neuroengineering and Therapeutics, University of Pennsylvania, 240 South 33rd Street, Philadelphia, PA 19104, United States
| | - Chloé E. Hill
- Department of Neurology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, United States
| | - Arjun Shankar
- Department of Bioengineering, University of Pennsylvania, 210 South 33rd Street, Philadelphia, PA 19104, United States,Center for Neuroengineering and Therapeutics, University of Pennsylvania, 240 South 33rd Street, Philadelphia, PA 19104, United States
| | - John Bernabei
- Department of Bioengineering, University of Pennsylvania, 210 South 33rd Street, Philadelphia, PA 19104, United States,Center for Neuroengineering and Therapeutics, University of Pennsylvania, 240 South 33rd Street, Philadelphia, PA 19104, United States
| | - Pouya Khankhanian
- Department of Neurology, University of Michigan, 1500 East Medical Center Drive, Ann Arbor, MI 48109, United States,Department of Neurology, Penn Epilepsy Center, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
| | - Brian Litt
- Department of Bioengineering, University of Pennsylvania, 210 South 33rd Street, Philadelphia, PA 19104, United States,Center for Neuroengineering and Therapeutics, University of Pennsylvania, 240 South 33rd Street, Philadelphia, PA 19104, United States,Department of Neurology, Penn Epilepsy Center, University of Pennsylvania, 3400 Spruce Street, Philadelphia, PA 19104, United States
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Kim H, Lee HJ, Kim YT, Son Y, Smielewski P, Czosnyka M, Kim DJ. Novel index for predicting mortality during the first 24 hours after traumatic brain injury. J Neurosurg 2019; 131:1887-1895. [PMID: 30579283 DOI: 10.3171/2018.7.jns18995] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/12/2018] [Accepted: 07/31/2018] [Indexed: 01/22/2023]
Abstract
OBJECTIVE Failure of cerebral autoregulation and subsequent hypoperfusion is common during the acute phase of traumatic brain injury (TBI). The cerebrovascular pressure-reactivity index (PRx) indirectly reflects cerebral autoregulation and has been used to derive optimal cerebral perfusion pressure (CPP). This study provides a method for the use of a combination of PRx, CPP, and intracranial pressure (ICP) to better evaluate the extent of cerebral hypoperfusion during the first 24 hours after TBI, allowing for a more accurate prediction of mortality risk. METHODS Continuous ICP and arterial blood pressure (ABP) signals acquired from 295 TBI patients during the first 24 hours after admission were retrospectively analyzed. The CPP at the lowest PRx was determined as the optimal CPP (CPPopt). The duration of a severe hypoperfusion event (dHP) was defined as the cumulative time that the PRx was > 0.2 and the CPP was < 70 mm Hg with the addition of intracranial hypertension (ICP > 20 or > 22 mm Hg). The outcome was determined as 6-month mortality. RESULTS The cumulative duration of PRx > 0.2 and CPP < 70 mm Hg exhibited a significant association with mortality (p < 0.001). When utilized with basic clinical information available during the first 24 hours after admission (i.e., Glasgow Coma Scale score, age, and mean ICP), a dHP > 25 minutes yielded a significant predictive capacity for mortality (p < 0.05, area under the curve [AUC] = 0.75). The parameter was particularly predictive of mortality for patients with a mean ICP > 20 or > 22 mm Hg (AUC = 0.81 and 0.87, respectively). CONCLUSIONS A short duration (25 minutes) of severe hypoperfusion, evaluated as lowered CPP during worsened cerebrovascular reactivity during the 1st day after TBI, is highly indicative of mortality.
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Affiliation(s)
- Hakseung Kim
- 1Department of Brain and Cognitive Engineering, Korea University, Seoul
| | - Hack-Jin Lee
- 1Department of Brain and Cognitive Engineering, Korea University, Seoul
| | - Young-Tak Kim
- 1Department of Brain and Cognitive Engineering, Korea University, Seoul
| | - Yunsik Son
- 2Department of Computer Engineering, Dongguk University, Seoul, South Korea
| | - Peter Smielewski
- 3Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
| | - Marek Czosnyka
- 3Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom; and
- 4Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Dong-Joo Kim
- 1Department of Brain and Cognitive Engineering, Korea University, Seoul
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Starnoni D, Maduri R, Hajdu SD, Pierzchala K, Giammattei L, Rocca A, Grosfilley SB, Saliou G, Messerer M, Daniel RT. Early Perfusion Computed Tomography Scan for Prediction of Vasospasm and Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2019; 130:e743-e752. [PMID: 31284055 DOI: 10.1016/j.wneu.2019.06.213] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2019] [Revised: 06/26/2019] [Accepted: 06/27/2019] [Indexed: 11/18/2022]
Abstract
OBJECTIVE We investigated the ability of early alteration of cerebral perfusion-computed tomography (PCT) parameters to predict the risk of vasospasm, delayed cerebral ischemia (DCI), and clinical outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective cohort study of 38 aSAH patients investigated with PCT within 48 hours after hemorrhage. Cerebral blood flow (CBF), cerebral blood volume, and mean transit time (MTT) values were recorded. Mean values were compared with clinical data. Vasospasm and DCI were determined by imaging and clinical criteria. Neurologic outcome was assessed by the modified Rankin Scale at discharge and 1-year follow-up visit. RESULTS More than a third (39.5%) of patients developed DCI, of whom 86.7% presented moderate-severe vasospasm. There was a significant correlation between perfusion parameters in the early phase and occurrence of DCI and vasospasm. The occurrence of DCI and vasospasm correlated significantly with lower mean early PCT values. DCI was correlated with lower mean early CBF values (P = 0.049) and vasospasm with lower mean CBF (P = 0.01) and MTT (P < 0.00001) values. MTT values of 5.5s were shown to have 94% specificity and 100% sensitivity for predicting the risk of developing vasospasm. The severity of the SAH according to the Barrow Neurological Institute scale correlated significantly with the risk of developing DCI and vasospasm, both significantly associated with unfavorable neurologic outcome (modified Rankin Scale score 3-6) (P = 0.0002 and P = 0.02, respectively). CONCLUSIONS Early alterations in PCT parameters and high Barrow Neurological Institute grade may identify a subgroup of patients at high risk of developing DCI and vasospasm after aSAH, thus prompting more robust preventative measures and treatment in this subgroup.
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Affiliation(s)
- Daniele Starnoni
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Rodolfo Maduri
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland.
| | - Steven David Hajdu
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | | | - Lorenzo Giammattei
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Alda Rocca
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Sarah Beatrice Grosfilley
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland
| | - Guillaume Saliou
- Department of Diagnostic and Interventional Radiology, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Mahmoud Messerer
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
| | - Roy Thomas Daniel
- Department of Clinical Neurosciences, Service of Neurosurgery, University Hospital of Lausanne (CHUV), Lausanne, Switzerland; Faculty of Biology and Medicine, University of Lausanne (UniL), Lausanne, Switzerland
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Clinical Usefulness of Transcranial Doppler as a Screening Tool for Early Cerebral Hypoxic Episodes in Patients with Moderate and Severe Traumatic Brain Injury. Neurocrit Care 2019; 32:486-491. [DOI: 10.1007/s12028-019-00763-y] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/28/2022]
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21
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Abstract
Neuromonitoring is important for patients with acute brain injury. The bedside neurologic examination is standard for neurologic monitoring; however, a clinical examination may not reliably detect subtle changes in intracranial physiology. Changes found during neurologic examinations are often late signs. The assessment of multiple physiological variables in real time can provide new clinical insights into treatment decisions. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism, such as in multimodal monitoring, allows an innovative approach to individualized patient care.
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Affiliation(s)
- Sarah H Peacock
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Amanda D Tomlinson
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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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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Abstract
PURPOSE OF REVIEW Here, we review the present state-of-the-art of microdialysis for monitoring patients with severe traumatic brain injury, highlighting the newest developments. Microdialysis has evolved in neurocritical care to become an established bedside monitoring modality that can reveal unique information on brain chemistry. RECENT FINDINGS A major advance is recent consensus guidelines for microdialysis use and interpretation. Other advances include insight obtained from microdialysis into the complex, interlinked traumatic brain injury disorders of electrophysiological changes, white matter injury, inflammation and metabolism. SUMMARY Microdialysis has matured into being a standard clinical monitoring modality that takes its place alongside intracranial pressure and brain tissue oxygen tension measurement in specialist neurocritical care centres, as well as being a research tool able to shed light on brain metabolism, inflammation, therapeutic approaches, blood-brain barrier transit and drug effects on downstream targets. Recent consensus on microdialysis monitoring is paving the way for improved neurocritical care protocols. Furthermore, there is scope for future improvements both in terms of the catheters and microdialysate analyser technology, which may further enhance its applicability.
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Kofler M, Schiefecker AJ, Beer R, Gaasch M, Rhomberg P, Stover J, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Enteral nutrition increases interstitial brain glucose levels in poor-grade subarachnoid hemorrhage patients. J Cereb Blood Flow Metab 2018; 38:518-527. [PMID: 28322077 PMCID: PMC5851142 DOI: 10.1177/0271678x17700434] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
Low brain tissue glucose levels after acute brain injury are associated with poor outcome. Whether enteral nutrition (EN) reliably increases cerebral glucose levels remains unclear. In this retrospective analysis of prospectively collected observational data, we investigate the effect of EN on brain metabolism in 17 poor-grade subarachnoid hemorrhage (SAH) patients undergoing cerebral microdialysis (CMD) monitoring. CMD-values were obtained hourly. A nutritional intervention was defined as the clinical routine administration of EN without supplemental parenteral nutrition. Sixty-three interventions were analyzed. The mean amount of EN per intervention was 472.4 ± 10.7 kcal. CMD-glucose levels significantly increased from 1.59 ± 0.13 mmol/l at baseline to a maximum of 2.03 ± 0.2 mmol/l after 5 h (p < 0.001), independently of insulin-treatment, baseline serum glucose, baseline brain metabolic distress (CMD-lactate-to-pyruvate-ratio (LPR) > 40) and the microdialysis probe location. The increase in CMD-glucose was directly dependent on the magnitude of increase of serum glucose levels (p = 0.007). No change in CMD-lactate, CMD-pyruvate, CMD-LPR, or CMD-glutamate (p > 0.4) was observed. Routine EN also increased CMD-glucose even if baseline concentrations were critically low ( < 0.7 mmol/l, neuroglucopenia; p < 0.001). These results may have treatment implications regarding glucose management of poor-grade aneurysmal SAH patients.
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Affiliation(s)
- Mario Kofler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J Schiefecker
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Ronny Beer
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Maxime Gaasch
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Paul Rhomberg
- 2 Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - John Stover
- 3 Fresenius Kabi, Bad Homburg vor der Höhe, Germany
| | - Bettina Pfausler
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- 4 Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Erich Schmutzhard
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- 1 Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Cerebrospinal fluid and brain extracellular fluid in severe brain trauma. HANDBOOK OF CLINICAL NEUROLOGY 2018; 146:237-258. [DOI: 10.1016/b978-0-12-804279-3.00014-9] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Oddo M, Hutchinson PJ. Understanding and monitoring brain injury: the role of cerebral microdialysis. Intensive Care Med 2017; 44:1945-1948. [DOI: 10.1007/s00134-017-5031-6] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/26/2017] [Accepted: 12/15/2017] [Indexed: 10/18/2022]
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28
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Zeiler FA, Thelin EP, Helmy A, Czosnyka M, Hutchinson PJA, Menon DK. A systematic review of cerebral microdialysis and outcomes in TBI: relationships to patient functional outcome, neurophysiologic measures, and tissue outcome. Acta Neurochir (Wien) 2017; 159:2245-2273. [PMID: 28988334 PMCID: PMC5686263 DOI: 10.1007/s00701-017-3338-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/19/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To perform a systematic review on commonly measured cerebral microdialysis (CMD) analytes and their association to: (A) patient functional outcome, (B) neurophysiologic measures, and (C) tissue outcome; after moderate/severe TBI. The aim was to provide a foundation for next-generation CMD studies and build on existing pragmatic expert guidelines for CMD. METHODS We searched MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to October 2016). Strength of evidence was adjudicated using GRADE. RESULTS (A) Functional Outcome: 55 articles were included, assessing outcome as mortality or Glasgow Outcome Scale (GOS) at 3-6 months post-injury. Overall, there is GRADE C evidence to support an association between CMD glucose, glutamate, glycerol, lactate, and LPR to patient outcome at 3-6 months. (B) Neurophysiologic Measures: 59 articles were included. Overall, there currently exists GRADE C level of evidence supporting an association between elevated CMD measured mean LPR, glutamate and glycerol with elevated ICP and/or decreased CPP. In addition, there currently exists GRADE C evidence to support an association between elevated mean lactate:pyruvate ratio (LPR) and low PbtO2. Remaining CMD measures and physiologic outcomes displayed GRADE D or no evidence to support a relationship. (C) Tissue Outcome: four studies were included. Given the conflicting literature, the only conclusion that can be drawn is acute/subacute phase elevation of CMD measured LPR is associated with frontal lobe atrophy at 6 months. CONCLUSIONS This systematic review replicates previously documented relationships between CMD and various outcome, which have driven clinical application of the technique. Evidence assessments do not address the application of CMD for exploring pathophysiology or titrating therapy in individual patients, and do not account for the modulatory effect of therapy on outcome, triggered at different CMD thresholds in individual centers. Our findings support clinical application of CMD and refinement of existing guidelines.
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Affiliation(s)
- Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Department of Clinical Neuroscience, Neurosurgical Research Laboratory, Karolinska University Hospital, Building R2:02, Karolinska Institutet, S-17176 Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Section of Brain Physics, Division of Neurosurgery, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Peter J. A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - David K. Menon
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
- Queens’ College, Cambridge, UK
- National Institute for Health Research, Southampton, UK
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Carteron L, Bouzat P, Oddo M. Cerebral Microdialysis Monitoring to Improve Individualized Neurointensive Care Therapy: An Update of Recent Clinical Data. Front Neurol 2017; 8:601. [PMID: 29180981 PMCID: PMC5693841 DOI: 10.3389/fneur.2017.00601] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/19/2017] [Accepted: 10/27/2017] [Indexed: 01/04/2023] Open
Abstract
Cerebral microdialysis (CMD) allows bedside semicontinuous monitoring of patient brain extracellular fluid. Clinical indications of CMD monitoring are focused on the management of secondary cerebral and systemic insults in acute brain injury (ABI) patients [mainly, traumatic brain injury (TBI), subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)], specifically to tailor several routine interventions—such as optimization of cerebral perfusion pressure, blood transfusion, glycemic control and oxygen therapy—in the individual patient. Using CMD as clinical research tool has greatly contributed to identify and better understand important post-injury mechanisms—such as energy dysfunction, posttraumatic glycolysis, post-aneurysmal early brain injury, cortical spreading depressions, and subclinical seizures. Main CMD metabolites (namely, lactate/pyruvate ratio, and glucose) can be used to monitor the brain response to specific interventions, to assess the extent of injury, and to inform about prognosis. Recent consensus statements have provided guidelines and recommendations for CMD monitoring in neurocritical care. Here, we summarize recent clinical investigation conducted in ABI patients, specifically focusing on the role of CMD to guide individualized intensive care therapy and to improve our understanding of the complex disease mechanisms occurring in the immediate phase following ABI. Promising brain biomarkers will also be described.
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Affiliation(s)
- Laurent Carteron
- Department of Anesthesiology and Intensive Care Medicine, University Hospital of Besançon, University of Bourgogne - Franche-Comté, Besançon, France
| | - Pierre Bouzat
- Department of Anesthesiology and Critical Care, University Hospital Grenoble, Grenoble, France
| | - Mauro Oddo
- Department of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV), University of Lausanne, Lausanne, Switzerland
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Abstract
The care of patients with traumatic brain injury can be one of the most challenging and rewarding aspects of clinical neurocritical care. This article reviews the approach to unique aspects specific to the care of this patient population. These aspects include appropriate use of sedation and analgesia, and the principles and the clinical use of intracranial monitors. Common clinical challenges encountered in these patients are also discussed, including the treatment of intracranial hypertension, temperature management, and control of sympathetic hyperactivity.
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Affiliation(s)
- Mohamed H Abou El Fadl
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA
| | - Kristine H O'Phelan
- Neurocritical Care, Department of Neurology, University of Miami, Miller School of Medicine, 1120 Northwest 14th Street, Suite 1356, Miami, FL 33136, USA.
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31
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Patet C, Quintard H, Zerlauth JB, Maibach T, Carteron L, Suys T, Bouzat P, Bervini D, Levivier M, Daniel RT, Eckert P, Meuli R, Oddo M. Bedside cerebral microdialysis monitoring of delayed cerebral hypoperfusion in comatose patients with poor grade aneurysmal subarachnoid haemorrhage. J Neurol Neurosurg Psychiatry 2017; 88:332-338. [PMID: 27927702 DOI: 10.1136/jnnp-2016-313766] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/13/2016] [Revised: 08/09/2016] [Accepted: 09/07/2016] [Indexed: 11/03/2022]
Abstract
BACKGROUND Delayed cerebral ischaemia (DCI) is frequent after poor grade aneurysmal subarachnoid haemorrhage (SAH). Owing to the limited accuracy of clinical examination, DCI diagnosis is often based on multimodal monitoring. We examined the value of cerebral microdialysis (CMD) in this setting. METHODS 20 comatose SAH participants underwent CMD monitoring-for hourly sampling of cerebral extracellular lactate/pyruvate ratio (LPR) and glucose-and brain perfusion CT (PCT). Patients were categorised as DCI when PCT (8±3 days after SAH) showed cerebral hypoperfusion, defined as cerebral blood flow <32.5 mL/100 g/min with a mean transit time >5.7 s. Clinicians were blinded to CMD data; for the purpose of the study, only patients who developed cerebral hypoperfusion in anterior and/or middle cerebral arteries were analysed. RESULTS DCI (n=9/20 patients) was associated with higher CMD LPR (51±36 vs 31±10 in patients without DCI, p=0.0007) and lower CMD glucose (0.64±0.34 vs 1.22±1.05, p=0.0005). In patients with DCI, CMD changes over the 18 hours preceding PCT diagnosis revealed a pattern of CMD LPR increase (coefficient +2.96 (95% CI 0.13 to 5.79), p=0.04) with simultaneous CMD glucose decrease (coefficient -0.06 (95% CI -0.08 to -0.01), p=0.03, mixed-effects multilevel regression model). No significant CMD changes were noted in patients without DCI. CONCLUSIONS In comatose patients with SAH, delayed cerebral hypoperfusion correlates with a CMD pattern of lactate increase and simultaneous glucose decrease. CMD abnormalities became apparent in the hours preceding PCT, thereby suggesting that CMD monitoring may anticipate targeted therapeutic interventions.
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Affiliation(s)
- Camille Patet
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Hervé Quintard
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland.,Department of Anesthesia and Critical Care, University Hospital, Nice, France
| | - Jean-Baptiste Zerlauth
- Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | | | - Laurent Carteron
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Tamarah Suys
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Pierre Bouzat
- Department of Anesthesia and Critical Care, University Hospital, Grenoble, France.,Neuroscience Institute, Grenoble, France
| | - David Bervini
- Division of Neurosurgery, Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Marc Levivier
- Division of Neurosurgery, Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Roy T Daniel
- Division of Neurosurgery, Clinical Neurosciences, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Philippe Eckert
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Reto Meuli
- Department of Radiology, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
| | - Mauro Oddo
- Neuroscience Critical Care Research Group, Departments of Intensive Care Medicine, Centre Hospitalier Universitaire Vaudois (CHUV)-Lausanne University Hospital, Lausanne, Switzerland
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Abstract
Critical care medicine came into sharp focus in the second part of the 20th century. The care of acutely ill neurologic patients in the USA may have originated in postoperative neurosurgical units, but for many years patients with neurocritical illness were admitted to intensive care units next to patients with general medical or surgical conditions. Neurologists may have had their first exposure to the complexity of neurocritical care during the poliomyelitis epidemics, but few were interested. Much later, the development of neurocritical care as a legitimate subspecialty was possible as a result of a new cadre of neurologists, with support by departments of neurosurgery and anesthesia, who appreciated their added knowledge and expertise in care of acute neurologic illness. Fellowship programs have matured in the US and training programs in certain European countries. Certification in the USA is possible through the American Academy of Neurology United Council of Neurologic Specialties. Most neurointensivists had a formal neurology training. This chapter is a brief analysis of the development of the specialty critical care neurology and how it gained strength, what it is to be a neurointensivist, what the future of care of these patients may hold, and what it takes for neurointensivists to stay exemplary. This chapter revisits some of the earlier known and previously unknown landmarks in the history of neurocritical care.
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Limnuson K, Narayan RK, Chiluwal A, Bouton C. Development of a brain monitoring system for multimodality investigation in awake rats. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2017; 2016:4487-4490. [PMID: 28269275 DOI: 10.1109/embc.2016.7591724] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
Multimodal brain monitoring is an important approach to gain insight into brain function, modulation, and pathology. We have developed a unique micromachined neural probe capable of real-time continuous monitoring of multiple physiological, biochemical and electrophysiological variables. However, to date, it has only been used in anesthetized animals due to a lack of an appropriate interface for awake animals. We have developed a versatile headstage for recording the small neural signal and bridging the sensors to the remote sensing units for multimodal brain monitoring in awake rats. The developed system has been successfully validated in awake rats by simultaneously measuring four cerebral variables: electrocorticography, oxygen tension, temperature and cerebral blood flow. Reliable signal recordings were obtained with minimal artifacts from movement and environmental noise. For the first time, multiple variables of cerebral function and metabolism were simultaneously recorded from awake rats using a single neural probe. The system is envisioned for studying the effects of pharmacologic treatments, mapping the development of central nervous system diseases, and better understanding normal cerebral physiology.
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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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35
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Vlodavsky E, Palzur E, Shehadeh M, Soustiel JF. Post-traumatic cytotoxic edema is directly related to mitochondrial function. J Cereb Blood Flow Metab 2017; 37:166-177. [PMID: 26672111 PMCID: PMC5363733 DOI: 10.1177/0271678x15621068] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/03/2015] [Revised: 10/26/2015] [Accepted: 11/11/2015] [Indexed: 01/15/2023]
Abstract
Cerebral edema represents a major threat following traumatic brain injury. However, therapeutic measures for control of intracranial pressure alone have failed to restore cerebral metabolism and improve neurological outcome. Since mitochondrial damage results in ATP depletion and deactivation of membrane ionic pumps, we hypothesized that modulation of ATP bioavailability may directly affect cytotoxic edema. Intracranial pressure measurements were performed in Sprague-Dawley rats treated by intraperitoneal injection of dimethylsulfoxide (vehicle), cyclosporine A (CsA), or Oligomycin B (OligB) following cortical contusion and further correlated with water content, mitochondrial damage, and electron microscopic assessment of neuronal and axonal edema. As hypothesized, ultra-structural figures of edema closely correlated with intracranial pressure elevation, increased water content and mitochondrial membrane permeabilization expressed by loss of transmembrane mitochondrial potential. Further, mitochondrial damage evidenced ultra-structurally by figures of swollen mitochondria with severely distorted cristae correlated with both cytotoxic edema and mitochondrial dysfunction. Importantly, cerebral edema and mitochondrial impairment were significantly worsened by treatment with OligB, whereas a noticeable improvement could be observed in animals that received injections of CsA. Since OligB and CsA are responsible for symmetrical and opposite effects on oxidative metabolism, these findings support the hypothesis of a causative relationship between edema and mitochondrial function.
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Affiliation(s)
- Eugene Vlodavsky
- Institute of Pathology, Rambam Medical Center, Haifa, Israel.,The Ruth & Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Eilam Palzur
- Eliachar Research Laboratory, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel
| | - Mona Shehadeh
- The Ruth & Bruce Rappaport Faculty of Medicine, Technion - Israel Institute of Technology, Haifa, Israel
| | - Jean F Soustiel
- Eliachar Research Laboratory, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel .,Department of Neurosurgery, Galilee Medical Center, Faculty of Medicine in the Galilee, University of Bar Ilan, Naharia, Israel
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de Vasconcelos FR, de Andrade AF, Teixeira MJ, Paiva WS. Monitoring brain multiparameters and hypothermia in severe traumatic brain injury. Neuropsychiatr Dis Treat 2017; 13:721-722. [PMID: 28331321 PMCID: PMC5352239 DOI: 10.2147/ndt.s122854] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
Affiliation(s)
| | - Almir Ferreira de Andrade
- Division of Neurological Surgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurological Surgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
| | - Wellingson Silva Paiva
- Division of Neurological Surgery, Department of Neurology, University of São Paulo Medical School, São Paulo, Brazil
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Jones S, Schwartzbauer G, Jia X. Brain Monitoring in Critically Neurologically Impaired Patients. Int J Mol Sci 2016; 18:E43. [PMID: 28035993 PMCID: PMC5297678 DOI: 10.3390/ijms18010043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/10/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023] Open
Abstract
Assessment of neurologic injury and the evolution of severe neurologic injury is limited in comatose or critically ill patients that lack a reliable neurologic examination. For common yet severe pathologies such as the comatose state after cardiac arrest, aneurysmal subarachnoid hemorrhage (aSAH), and severe traumatic brain injury (TBI), critical medical decisions are made on the basis of the neurologic injury. Decisions regarding active intensive care management, need for neurosurgical intervention, and withdrawal of care, depend on a reliable, high-quality assessment of the true state of neurologic injury, and have traditionally relied on limited assessments such as intracranial pressure monitoring and electroencephalogram. However, even within TBI there exists a spectrum of disease that is likely not captured by such limited monitoring and thus a more directed effort towards obtaining a more robust biophysical signature of the individual patient must be undertaken. In this review, multimodal monitoring including the most promising serum markers of neuronal injury, cerebral microdialysis, brain tissue oxygenation, and pressure reactivity index to access brain microenvironment will be discussed with their utility among specific pathologies that may help determine a more complete picture of the neurologic injury state for active intensive care management and long-term outcomes. Goal-directed therapy guided by a multi-modality approach appears to be superior to standard intracranial pressure (ICP) guided therapy and should be explored further across multiple pathologies. Future directions including the application of optogenetics to evaluate brain injury and recovery and even as an adjunct monitoring modality will also be discussed.
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Affiliation(s)
- Salazar Jones
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Regional cerebral blood flow and cellular environment in subarachnoid hemorrhage: A thermal doppler flowmetry and microdialysis study. Neurol Neurochir Pol 2016; 51:66-71. [PMID: 27908617 DOI: 10.1016/j.pjnns.2016.11.002] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/07/2016] [Revised: 08/19/2016] [Accepted: 11/09/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Cerebral microdialysis enables assessment of regional metabolic physiology and provides biomarkers for clinical correlation in critical conditions, such as subarachnoid hemorrhage (SAH). The aim of our current study was to investigate the correlation between regional cerebral blood flow and microdialysis parameters (glucose, lactate, glycerol, pyruvate concentrations, and lactate/pyruvate metabolic ratio) in patients with SAH. MATERIALS AND METHODS Twenty-one patients with SAH were enrolled in our retrospective study. Cerebral blood flow (CBF) based on thermal diffusion methodology, the thermal coefficient K, and microdialysis biochemical markers were recorded. The duration of the brain monitoring was 10 days. RESULTS Microdialysis glucose concentration was inversely related to the cerebral temperature and to the L/P ratio. Furthermore, it was positively correlated to all other microdialysis parameters but glycerol. The K coefficient was strongly and positively correlated with the temperature and marginally with the CBF. The L/P ratio was positively correlated with glycerol, while it was inversely correlated with the CBF. Patients who died had elevated L/P ratio and K coefficient compared to the survivors in our series. CONCLUSIONS Thermal conductivity coefficient may change over time as cerebral injury progresses and tissue properties alter. These alterations were found to be associated with the microdialysis metabolite concentrations and the CBF itself. The microdialysis biochemical indices of cell stress and death (glycerol, L/P ratio) were positively related to each other, while the measured L/P metabolic ratio was higher among patients who died.
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Subdural Empyema in the Setting of Multimodal Intracranial Monitoring. World Neurosurg 2016; 97:749.e1-749.e6. [PMID: 27826090 DOI: 10.1016/j.wneu.2016.10.133] [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: 10/12/2016] [Revised: 10/26/2016] [Accepted: 10/28/2016] [Indexed: 11/20/2022]
Abstract
BACKGROUND Multimodal intracranial monitoring is becoming an increasingly common tool in the management of patients with traumatic brain injury. Although numerous reports detailing the benefits of such advanced monitoring exist in the literature, there is minimal discussion of the possible complications that may arise in this patient population. CASE DESCRIPTION We report the case of a 32-year-old patient who had been assaulted and presented initially at an outside facility with a Glasgow Coma Scale score of 8. After transfer to our hospital, his Glasgow Coma Scale score was noted at 7T and multimodal monitoring with the Integra Licox brain tissue oxygen monitor and the Hemedex Bowman perfusion monitor was implemented, along with an external ventricular drain when a standard intracranial pressure monitor indicated increasing intracranial pressure. The patient's intracranial pressure normalized but he did require a course of antibiotics during this time for a fever and methicillin-resistant Staphylococcus aureus. The patient subsequently developed multifocal subdural empyemas requiring surgical evacuation. Postoperatively, the patient's intraoperative cultures remained without bacterial growth, likely related to the 2-week broad-spectrum antibiotic use. CONCLUSIONS To our knowledge, this is the first reported incidence of a subdural empyema developing in this setting. Although the safety profile of multimodal intracranial modeling is excellent, with increasing numbers of invasive bedside procedures, neurosurgeons must remain acutely vigilant for the development of infectious complications.
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Grindlinger GA, Skavdahl DH, Ecker RD, Sanborn MR. Decompressive craniectomy for severe traumatic brain injury: clinical study, literature review and meta-analysis. SPRINGERPLUS 2016; 5:1605. [PMID: 27652178 PMCID: PMC5028365 DOI: 10.1186/s40064-016-3251-9] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 04/14/2016] [Accepted: 09/08/2016] [Indexed: 11/30/2022]
Abstract
OBJECTIVE To examine the clinical and neurological outcome of patients who sustained a severe non-penetrating traumatic brain injury (TBI) and underwent unilateral decompressive craniectomy (DC) for refractory intracranial hypertension. DESIGN Single center, retrospective, observational. SETTING Level I Trauma Center in Portland, Maine. PATIENTS 31 patients aged 16-72 of either sex who sustained a severe, non-penetrating TBI and underwent a unilateral DC for evacuation of parenchymal or extra-axial hematoma or for failure of medical therapy to control intracranial pressure (ICP). INTERVENTIONS Review of the electronic medical record of patients undergoing DC for severe TBI and assessment of extended Glasgow Outcome Score (e-GOS) at 6-months following DC. MEASUREMENTS AND MAIN RESULTS The mean age was 39.3y ± 14.5. The initial GCS was 5.8 ± 3.2, and the ISS was 29.7 ± 6.3. Twenty-two patients underwent DC within the first 24 h, two within the next 24 h and seven between the 3rd and 7th day post injury. The pre-DC ICP was 30.7 ± 10.3 and the ICP was 12.1 ± 6.2 post-DC. Cranioplasty was performed in all surviving patients 1-4 months post-DC. Of the 29 survivors following DC, the e-GOS was 8 in seven patients, and 7 in ten patients. The e-GOS was 5-6 in 6 others. Of the 6 survivors with poor outcomes (e-GOS = 2-4), five were the initial patients in the series. CONCLUSIONS In patients with intractable cerebral hypertension following TBI, unilateral DC in concert with practice guideline directed brain resuscitation is associated with good functional outcome and acceptable-mortality.
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Affiliation(s)
- Gene A. Grindlinger
- Maine Medical Center, 887 Congress Street, Suite 210, Portland, ME 04102 USA
- Tufts University School of Medicine, Boston, MA USA
| | - David H. Skavdahl
- Surgical Residency Program, Maine Medical Center, Portland, ME USA
- Tufts University School of Medicine, Boston, MA USA
| | - Robert D. Ecker
- Tufts University School of Medicine, Boston, MA USA
- Department of Neurosurgery, Maine Medical Center, Portland, ME USA
| | - Matthew R. Sanborn
- Tufts University School of Medicine, Boston, MA USA
- Department of Neurosurgery, Maine Medical Center, Portland, ME USA
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41
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Development and application of a microfabricated multimodal neural catheter for neuroscience. Biomed Microdevices 2016; 18:8. [PMID: 26780443 DOI: 10.1007/s10544-016-0034-6] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022]
Abstract
We present a microfabricated neural catheter for real-time continuous monitoring of multiple physiological, biochemical and electrophysiological variables that are critical to the diagnosis and treatment of evolving brain injury. The first generation neural catheter was realized by polyimide-based micromachining and a spiral rolling packaging method. The mechanical design and electrical operation of the microsensors were optimized and tailored for multimodal monitoring in rat brain such that the potential thermal, chemical and electrical crosstalk among the microsensors as well as errors from micro-environmental fluctuations are minimized. In vitro cytotoxicity analyses suggest that the developed neural catheters are minimally toxic to rat cortical neuronal cultures. In addition, in vivo histopathology results showed neither acute nor chronic inflammation for 7 days post implantation. The performance of the neural catheter was assessed in an in vivo needle prick model as a translational replica of a "mini" traumatic brain injury. It successfully monitored the expected transient brain oxygen, temperature, regional cerebral blood flow, and DC potential changes during the passage of spreading depolarization waves. We envisage that the developed multimodal neural catheter can be used to decipher the causes and consequences of secondary brain injury processes with high spatial and temporal resolution while reducing the potential for iatrogenic injury inherent to current use of multiple invasive probes.
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42
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Limnuson K, Narayan RK, Chiluwal A, Golanov EV, Bouton CE, Li C. A User-Configurable Headstage for Multimodality Neuromonitoring in Freely Moving Rats. Front Neurosci 2016; 10:382. [PMID: 27594826 PMCID: PMC4990626 DOI: 10.3389/fnins.2016.00382] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2016] [Accepted: 08/05/2016] [Indexed: 11/21/2022] Open
Abstract
Multimodal monitoring of brain activity, physiology, and neurochemistry is an important approach to gain insight into brain function, modulation, and pathology. With recent progress in micro- and nanotechnology, micro-nano-implants have become important catalysts in advancing brain research. However, to date, only a limited number of brain parameters have been measured simultaneously in awake animals in spite of significant recent progress in sensor technology. Here we have provided a cost and time effective approach to designing a headstage to conduct a multimodality brain monitoring in freely moving animals. To demonstrate this method, we have designed a user-configurable headstage for our micromachined multimodal neural probe. The headstage can reliably record direct-current electrocorticography (DC-ECoG), brain oxygen tension (PbrO2), cortical temperature, and regional cerebral blood flow (rCBF) simultaneously without significant signal crosstalk or movement artifacts for 72 h. Even in a noisy environment, it can record low-level neural signals with high quality. Moreover, it can easily interface with signal conditioning circuits that have high power consumption and are difficult to miniaturize. To the best of our knowledge, this is the first time where multiple physiological, biochemical, and electrophysiological cerebral variables have been simultaneously recorded from freely moving rats. We anticipate that the developed system will aid in gaining further insight into not only normal cerebral functioning but also pathophysiology of conditions such as epilepsy, stroke, and traumatic brain injury.
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Affiliation(s)
- Kanokwan Limnuson
- Cushing Neuromonitoring Laboratory, The Feinstein Institute for Medical Research Manhasset, NY, USA
| | - Raj K Narayan
- Cushing Neuromonitoring Laboratory, The Feinstein Institute for Medical ResearchManhasset, NY, USA; Department of Neurosurgery, Hofstra Northwell School of MedicineHempstead, NY, USA
| | - Amrit Chiluwal
- Department of Neurosurgery, Hofstra Northwell School of Medicine Hempstead, NY, USA
| | - Eugene V Golanov
- Cushing Neuromonitoring Laboratory, The Feinstein Institute for Medical Research Manhasset, NY, USA
| | - Chad E Bouton
- Center for Bioelectronic Medicine, The Feinstein Institute for Medical Research Manhasset, NY, USA
| | - Chunyan Li
- Cushing Neuromonitoring Laboratory, The Feinstein Institute for Medical ResearchManhasset, NY, USA; Department of Neurosurgery, Hofstra Northwell School of MedicineHempstead, NY, USA; Center for Bioelectronic Medicine, The Feinstein Institute for Medical ResearchManhasset, NY, USA
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Abstract
PURPOSE OF REVIEW Monitoring and therapy of patients in neurocritical care are areas of intensive research and the current evidence needs further confirmation. RECENT FINDINGS A consensus statement of the Neurocritical Care Society and the European Society of Intensive Care Medicine provided pragmatic guidance and recommendations for multimodal monitoring in neurocritical care patients. Only a minority of these recommendations have strong evidence. In addition, recent multicenter randomized controlled trials concerning the therapy of subarachnoidal hemorrhage and traumatic brain injury could not show decreased mortality or improved functional neurologic outcome after the interventions. The current evidence for monitoring and medical therapy in patients after traumatic brain injury and aneurysmal subarachnoid hemorrhage is highlighted in this review. SUMMARY Although strong evidence is lacking, multimodal monitoring is of great value in neurocritical care patients and may help to provide patients with the optimal therapy based on the individual pathophysiological changes.
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Abstract
The challenges posed by acute brain injury (ABI) involve the management of the initial insult in addition to downstream inflammation, edema, and ischemia that can result in secondary brain injury (SBI). SBI is often subclinical, but can be detected through physiologic changes. These changes serve as a surrogate for tissue injury/cell death and are captured by parameters measured by various monitors that measure intracranial pressure (ICP), cerebral blood flow (CBF), brain tissue oxygenation (PbtO2), cerebral metabolism, and electrocortical activity. In the ideal setting, multimodality monitoring (MMM) integrates these neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances and questions regarding its use. In this review, we examine these recommendations, recent evidence for MMM, and future directions for MMM.
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Affiliation(s)
- David Roh
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
| | - Soojin Park
- Department of Neurology and Neurocritical Care, Columbia University, 177 Fort Washington Ave, New York, NY 10032, USA
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Claassen J, Rahman SA, Huang Y, Frey HP, Schmidt JM, Albers D, Falo CM, Park S, Agarwal S, Connolly ES, Kleinberg S. Causal Structure of Brain Physiology after Brain Injury from Subarachnoid Hemorrhage. PLoS One 2016; 11:e0149878. [PMID: 27123582 PMCID: PMC4849773 DOI: 10.1371/journal.pone.0149878] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/13/2015] [Accepted: 02/06/2016] [Indexed: 11/19/2022] Open
Abstract
High frequency physiologic data are routinely generated for intensive care patients. While massive amounts of data make it difficult for clinicians to extract meaningful signals, these data could provide insight into the state of critically ill patients and guide interventions. We develop uniquely customized computational methods to uncover the causal structure within systemic and brain physiologic measures recorded in a neurological intensive care unit after subarachnoid hemorrhage. While the data have many missing values, poor signal-to-noise ratio, and are composed from a heterogeneous patient population, our advanced imputation and causal inference techniques enable physiologic models to be learned for individuals. Our analyses confirm that complex physiologic relationships including demand and supply of oxygen underlie brain oxygen measurements and that mechanisms for brain swelling early after injury may differ from those that develop in a delayed fashion. These inference methods will enable wider use of ICU data to understand patient physiology.
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Affiliation(s)
- Jan Claassen
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
- * E-mail:
| | - Shah Atiqur Rahman
- Computer Science Department, Stevens Institute of Technology, Hoboken, NJ, United States of America
| | - Yuxiao Huang
- Computer Science Department, Stevens Institute of Technology, Hoboken, NJ, United States of America
| | - Hans-Peter Frey
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - J. Michael Schmidt
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - David Albers
- Department of Biomedical Informatics, Columbia University, New York, NY, United States of America
| | - Cristina Maria Falo
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - Soojin Park
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - Sachin Agarwal
- Division of Critical Care Neurology, Department of Neurology, Columbia University, New York, NY, United States of America
| | - E. Sander Connolly
- Department of Neurosurgery, Columbia University, New York, NY, United States of America
| | - Samantha Kleinberg
- Computer Science Department, Stevens Institute of Technology, Hoboken, NJ, United States of America
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Quintard H, Patet C, Zerlauth JB, Suys T, Bouzat P, Pellerin L, Meuli R, Magistretti PJ, Oddo M. Improvement of Neuroenergetics by Hypertonic Lactate Therapy in Patients with Traumatic Brain Injury Is Dependent on Baseline Cerebral Lactate/Pyruvate Ratio. J Neurotrauma 2015; 33:681-7. [PMID: 26421521 PMCID: PMC4827289 DOI: 10.1089/neu.2015.4057] [Citation(s) in RCA: 56] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
Abstract
Energy dysfunction is associated with worse prognosis after traumatic brain injury (TBI). Recent data suggest that hypertonic sodium lactate infusion (HL) improves energy metabolism after TBI. Here, we specifically examined whether the efficacy of HL (3h infusion, 30–40 μmol/kg/min) in improving brain energetics (using cerebral microdialysis [CMD] glucose as a main therapeutic end-point) was dependent on baseline cerebral metabolic state (assessed by CMD lactate/pyruvate ratio [LPR]) and cerebral blood flow (CBF, measured with perfusion computed tomography [PCT]). Using a prospective cohort of 24 severe TBI patients, we found CMD glucose increase during HL was significant only in the subgroup of patients with elevated CMD LPR >25 (n = 13; +0.13 [95% confidence interval (CI) 0.08–0.19] mmol/L, p < 0.001; vs. +0.04 [–0.05–0.13] in those with normal LPR, p = 0.33, mixed-effects model). In contrast, CMD glucose increase was independent from baseline CBF (coefficient +0.13 [0.04–0.21] mmol/L when global CBF was <32.5 mL/100 g/min vs. +0.09 [0.04–0.14] mmol/L at normal CBF, both p < 0.005) and systemic glucose. Our data suggest that improvement of brain energetics upon HL seems predominantly dependent on baseline cerebral metabolic state and support the concept that CMD LPR – rather than CBF – could be used as a diagnostic indication for systemic lactate supplementation following TBI.
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Affiliation(s)
- Hervé Quintard
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland .,2 Department of Anesthesia and Intensive Care, Nice University Hospital , Nice, France
| | - Camille Patet
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Jean-Baptiste Zerlauth
- 3 Department of Medical Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Tamarah Suys
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Pierre Bouzat
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland .,4 Department of Anesthesia and Intensive Care, Grenoble University Hospital , Grenoble, France
| | - Luc Pellerin
- 5 Institute of Physiology, University of Lausanne , Lausanne, Switzerland
| | - Reto Meuli
- 3 Department of Medical Radiology, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
| | - Pierre J Magistretti
- 6 Division of Biological and Environmental Sciences and Engineering, King Abdullah University of Science and Technology (KAUST) , Thuwal, Kingdom of Saudi Arabia .,7 Centre de Neurosciences Psychiatriques, Department of Psychiatry, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland .,8 Laboratory of Neuroenergetics and Cellular Dynamics, Brain Mind Institute , Ecole Polytechnique Fédérale de Lausanne (EPFL), Lausanne, Switzerland
| | - Mauro Oddo
- 1 Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, Centre Hospitalier Universitaire Vaudois (CHUV), Lausanne University Hospital , Lausanne, Switzerland
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Nouveaux outils de neuromonitorage. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1099-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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49
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Translating Conceptual Guidelines in Clinical Progress?*. Crit Care Med 2015; 43:1537-9. [DOI: 10.1097/ccm.0000000000001034] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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