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Thudium M, Kappler J, Oremek MJG, Ehrentraut SF, Kornilov E, Marinova M, Putensen C, Soehle M, Schewe JC. Increased impairment of cerebral autoregulation in COVID-19 associated pulmonary failure requiring extracorporeal membrane oxygenation. Front Med (Lausanne) 2024; 11:1423241. [PMID: 39011454 PMCID: PMC11246866 DOI: 10.3389/fmed.2024.1423241] [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: 04/25/2024] [Accepted: 06/20/2024] [Indexed: 07/17/2024] Open
Abstract
Introduction Cerebrovascular complications are feared but also commonly reported in patients with COVID-19 requiring extracorporeal membrane oxygenation (ECMO) support therapy. Besides other reasons, a connection between impaired cerebral autoregulation and SARS-CoV-2 infection as a mechanism for an increase in cerebrovascular complications has been hypothesized. Methods In an observational single-center study, we investigated a cohort of 48 patients requiring veno-venous ECMO support therapy with (n = 31) and without SARS-CoV-2 infection (n = 17). Cerebral autoregulation was assessed with the cerebral oximetry-derived autoregulation index (ORx) based on a moving correlation between arterial pressure and cerebral oximetry. Results Patients with ECMO support therapy and SARS-CoV-2 experienced more time with impaired cerebral autoregulation than without SARS-CoV-2 [17 ± 9 vs. 13 ± 9% (p = 0.027)]. Patients with SARS-CoV-2 suffering from cerebrovascular complications had more time with impaired autoregulation than non SARS-CoV-2 patients with these complications (19 ± 9 vs. 10 ± 4%, p = 0.032). Conclusion Our results suggest a connection between SARS-CoV-2 and impaired cerebral autoregulation as well as cerebrovascular complications in SARS-CoV-2 patients.
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Affiliation(s)
- Marcus Thudium
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Jochen Kappler
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Maximilian J G Oremek
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Stefan Felix Ehrentraut
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Evgeniya Kornilov
- Department of Neurobiology, Weizmann Institute of Science, Rehovot, Israel
| | - Milka Marinova
- Department of Nuclear Medicine, University Hospital Bonn, Bonn, Germany
| | - Christian Putensen
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Martin Soehle
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
| | - Jens-Christian Schewe
- Department of Anesthesiology and Intensive Care Medicine, University Hospital Bonn, Bonn, Germany
- Department of Anesthesiology, Intensive Care Medicine and Pain Therapy, University Medical Center Rostock, Rostock, Germany
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2
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Katayama T, Takahashi K, Yahara O. Atrial fibrillation, hypertension, and the cerebral vasodilatory reserve. Hypertens Res 2024:10.1038/s41440-024-01758-9. [PMID: 38898245 DOI: 10.1038/s41440-024-01758-9] [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: 04/23/2024] [Revised: 05/16/2024] [Accepted: 05/28/2024] [Indexed: 06/21/2024]
Abstract
Schematic representation for the cascade model of atrial fibrillation, hypertension, the cerebral vasodilatory reserve, and cognitive decline.
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Affiliation(s)
| | - Kae Takahashi
- Department of Neurology, Asahikawa City Hospital, Asahikawa, Japan
| | - Osamu Yahara
- Department of Neurology, Asahikawa City Hospital, Asahikawa, Japan
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3
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Fedriga M, Martini S, Iodice FG, Sortica da Costa C, Pezzato S, Moscatelli A, Beqiri E, Czosnyka M, Smielewski P, Agrawal S. Cerebral autoregulation in paediatric and neonatal intensive care: A scoping review. J Cereb Blood Flow Metab 2024:271678X241261944. [PMID: 38867574 DOI: 10.1177/0271678x241261944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 06/14/2024]
Abstract
Deranged cerebral autoregulation (CA) is associated with worse outcome in adult brain injury. Strategies for monitoring CA and maintaining the brain at its 'best CA status' have been implemented, however, this approach has not yet developed for the paediatric population. This scoping review aims to find up-to-date evidence on CA assessment in children and neonates with a view to identify patient categories in which CA has been measured so far, CA monitoring methods and its relationship with clinical outcome if any. A literature search was conducted for studies published within 31st December 2022 in 3 bibliographic databases. Out of 494 papers screened, this review includes 135 studies. Our literature search reveals evidence for CA measurement in the paediatric population across different diagnostic categories and age groups. The techniques adopted, indices and thresholds used to assess and define CA are heterogeneous. We discuss the relevance of available evidence for CA assessment in the paediatric population. However, due to small number of studies and heterogeneity of methods used, there is no conclusive evidence to support universal adoption of CA monitoring, technique, and methodology. This calls for further work to understand the clinical impact of CA monitoring in paediatric and neonatal intensive care.
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Affiliation(s)
- Marta Fedriga
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Silvia Martini
- Neonatal Intensive Care Unit, IRCCS AOUBO, Department of Medical and Surgical Sciences, University of Bologna, Bologna, Italy
| | - Francesca G Iodice
- Paediatric Cardiac Anaesthesia and Intensive Care Unit, IRCCS, Bambino Gesu' Hospital, Rome, Italy
| | | | - Stefano Pezzato
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Andrea Moscatelli
- Neonatal and Paediatric Intensive Care Unit, IRCCS Giannina Gaslini Institute, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Shruti Agrawal
- Department of Paediatric Intensive Care, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
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4
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Karlsen H, Strand-Amundsen RJ, Skåre C, Eriksen M, Skulberg VM, Sunde K, Tønnessen TI, Olasveengen TM. Cerebral perfusion and metabolism with mild hypercapnia vs. normocapnia in a porcine post cardiac arrest model with and without targeted temperature management. Resusc Plus 2024; 18:100604. [PMID: 38510376 PMCID: PMC10950799 DOI: 10.1016/j.resplu.2024.100604] [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: 12/08/2023] [Revised: 02/15/2024] [Accepted: 03/03/2024] [Indexed: 03/22/2024] Open
Abstract
Aim To determine whether targeting mild hypercapnia (PaCO2 7 kPa) would yield improved cerebral blood flow and metabolism compared to normocapnia (PaCO2 5 kPa) with and without targeted temperature management to 33 °C (TTM33) in a porcine post-cardiac arrest model. Methods 39 pigs were resuscitated after 10 minutes of cardiac arrest using cardiopulmonary bypass and randomised to TTM33 or no-TTM, and hypercapnia or normocapnia. TTM33 was managed with intravasal cooling. Animals were stabilized for 30 minutes followed by a two-hour intervention period. Hemodynamic parameters were measured continuously, and neuromonitoring included intracranial pressure (ICP), pressure reactivity index, cerebral blood flow, brain-tissue pCO2 and microdialysis. Measurements are reported as proportion of baseline, and areas under the curve during the 120 min intervention period were compared. Results Hypercapnia increased cerebral flow in both TTM33 and no-TTM groups, but also increased ICP (199% vs. 183% of baseline, p = 0.018) and reduced cerebral perfusion pressure (70% vs. 84% of baseline, p < 0.001) in no-TTM animals. Cerebral lactate (196% vs. 297% of baseline, p < 0.001), pyruvate (118% vs. 152% of baseline, p < 0.001), glycerol and lactate/pyruvate ratios were lower with hypercapnia in the TTM33 group, but only pyruvate (133% vs. 150% of baseline, p = 0.002) was lower with hypercapnia among no-TTM animals. Conclusion In this porcine post-arrest model, hypercapnia led to increased cerebral flow both with and without hypothermia, but also increased ICP and reduced cerebral perfusion pressure in no-TTM animals. The effects of hypercapnia were different with and without TTM.(Institutional protocol number: FOTS, id 14931).
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Affiliation(s)
- Hilde Karlsen
- Department of Research and Development and Institute for Experimental Medical Research, Oslo University Hospital, Norway
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | | | - Christiane Skåre
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
- University of Oslo, Oslo, Norway
| | - Morten Eriksen
- Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | - Vidar M Skulberg
- Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
| | - Tor Inge Tønnessen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
| | - Theresa M Olasveengen
- Institute of Clinical Medicine, University of Oslo, Oslo, Norway
- Department of Anesthesia and Intensive Care Medicine, Oslo University Hospital, Oslo, Norway
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5
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Lipszyc AC, Walker SCD, Beech AP, Wilding H, Akhlaghi H. Predicting Fluid Responsiveness Using Carotid Ultrasound in Mechanically Ventilated Patients: A Systematic Review and Meta-Analysis of Diagnostic Test Accuracy Studies. Anesth Analg 2024; 138:1174-1186. [PMID: 38289868 DOI: 10.1213/ane.0000000000006820] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/01/2024]
Abstract
BACKGROUND A noninvasive and accurate method of determining fluid responsiveness in ventilated patients would help to mitigate unnecessary fluid administration. Although carotid ultrasound has been previously studied for this purpose, several studies have recently been published. We performed an updated systematic review and meta-analysis to evaluate the accuracy of carotid ultrasound as a tool to predict fluid responsiveness in ventilated patients. METHODS Studies eligible for review investigated the accuracy of carotid ultrasound parameters in predicting fluid responsiveness in ventilated patients, using sensitivity and specificity as markers of diagnostic accuracy (International Prospective Register of Systematic Reviews [PROSPERO] CRD42022380284). All included studies had to use an independent method of determining cardiac output and exclude spontaneously ventilated patients. Six bibliographic databases and 2 trial registries were searched. Medline, Embase, Emcare, APA PsycInfo, CINAHL, and the Cochrane Library were searched on November 4, 2022. Clinicaltrials.gov and Australian New Zealand Clinical Trials Registry were searched on February 24, 2023. Results were pooled, meta-analysis was conducted where possible, and hierarchical summary receiver operating characteristic models were used to compare carotid ultrasound parameters. Bias and evidence quality were assessed using the Quality Assessment of Diagnostic Accuracy Studies (QUADAS) tool and the Grading of Recommendations, Assessment, Development, and Evaluations (GRADE) guidelines. RESULTS Thirteen prospective clinical studies were included (n = 648 patients), representing 677 deliveries of volume expansion, with 378 episodes of fluid responsiveness (58.3%). A meta-analysis of change in carotid Doppler peak velocity (∆CDPV) yielded a sensitivity of 0.79 (95% confidence interval [CI], 0.74-0.84) and a specificity of 0.85 (95% CI, 0.76-0.90). Risk of bias relating to recruitment methodology, the independence of index testing to reference standards and exclusionary clinical criteria were evaluated. Overall quality of evidence was low. Study design heterogeneity, including a lack of clear parameter cutoffs, limited the generalizability of our results. CONCLUSIONS In this meta-analysis, we found that existing literature supports the ability of carotid ultrasound to predict fluid responsiveness in mechanically ventilated adults. ∆CDPV may be an accurate carotid parameter in certain contexts. Further high-quality studies with more homogenous designs are needed to further validate this technology.
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Affiliation(s)
- Adam C Lipszyc
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Samuel C D Walker
- Department of Emergency Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
| | - Alexander P Beech
- From the Department of Anaesthesia and Acute Pain Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Helen Wilding
- Library Service, St Vincent's Hospital, Melbourne, Victoria, Australia
| | - Hamed Akhlaghi
- Department of Emergency Medicine, St Vincent's Hospital, Melbourne, Victoria, Australia
- Department of Medical Education, University of Melbourne, Melbourne, Victoria, Australia
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6
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Malinova V, Kranawetter B, Tuzi S, Moerer O, Rohde V, Mielke D. Optimal cerebral perfusion pressure in aneurysmal subarachnoid hemorrhage and its relation to perfusion deficits on CT-perfusion. J Cereb Blood Flow Metab 2024:271678X241237879. [PMID: 38708962 DOI: 10.1177/0271678x241237879] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Preservation of optimal cerebral perfusion is a crucial part of the acute management after aneurysmal subarachnoid hemorrhage (aSAH). A few studies indicated possible benefits of maintaining a cerebral perfusion pressure (CPP) near the calculated optimal CPP (CPPopt), representing an individually optimal condition at which cerebral autoregulation functions at its best. This retrospective observational monocenter study was conducted to investigate, whether "suboptimal" perfusion with actual CPP deviating from CPPopt correlates with perfusion deficits detected by CT-perfusion (CTP). A consecutive cohort of aSAH-patients was reviewed and patients with available parameters for CPPopt-calculation, who simultaneously received CTP, were analyzed. By plotting the pressure reactivity index (PRx) versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. Perfusion deficits on CTP were documented. In 86 out of 324 patients, the inclusion criteria were met. Perfusion deficits were detected in 47% (40/86) of patients. In 43% of patients, CPP was lower than CPPopt, which correlated with detected perfusion deficits (r = 0.23, p = 0.03). Perfusion deficits were found in 62% of patients with CPPCPPopt (OR 3, p = 0.01). These findings support the hypothesis, that a deviation of CPP from CPPopt is an indicator of suboptimal cerebral perfusion.
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Affiliation(s)
- Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Beate Kranawetter
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Sheri Tuzi
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Göttingen, Germany
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7
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Appavu B, Kirschen MP, Bell M. Neuromonitoring in Pediatric Neurocritical Care: An Introduction. Neurocrit Care 2024:10.1007/s12028-024-01988-2. [PMID: 38689192 DOI: 10.1007/s12028-024-01988-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Accepted: 03/21/2024] [Indexed: 05/02/2024]
Affiliation(s)
- Brian Appavu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA.
- Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E. Van Buren Street, Phoenix, AZ, 85004, USA.
| | - Matthew P Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia, Perelman School of Medicine at the University of Pennsylvania, Philadelphia, PA, USA
| | - Michael Bell
- Division of Critical Care Medicine, Department of Pediatrics, Children's National Medical Center, Washington, DC, USA
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8
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Lengyel B, Magyar-Stang R, Pál H, Debreczeni R, Sándor ÁD, Székely A, Gyürki D, Csippa B, István L, Kovács I, Sótonyi P, Mihály Z. Non-Invasive Tools in Perioperative Stroke Risk Assessment for Asymptomatic Carotid Artery Stenosis with a Focus on the Circle of Willis. J Clin Med 2024; 13:2487. [PMID: 38731014 PMCID: PMC11084304 DOI: 10.3390/jcm13092487] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2024] [Revised: 04/17/2024] [Accepted: 04/20/2024] [Indexed: 05/13/2024] Open
Abstract
This review aims to explore advancements in perioperative ischemic stroke risk estimation for asymptomatic patients with significant carotid artery stenosis, focusing on Circle of Willis (CoW) morphology based on the CTA or MR diagnostic imaging in the current preoperative diagnostic algorithm. Functional transcranial Doppler (fTCD), near-infrared spectroscopy (NIRS), and optical coherence tomography angiography (OCTA) are discussed in the context of evaluating cerebrovascular reserve capacity and collateral vascular systems, particularly the CoW. These non-invasive diagnostic tools provide additional valuable insights into the cerebral perfusion status. They support biomedical modeling as the gold standard for the prediction of the potential impact of carotid artery stenosis on the hemodynamic changes of cerebral perfusion. Intraoperative risk assessment strategies, including selective shunting, are explored with a focus on CoW variations and their implications for perioperative ischemic stroke and cognitive function decline. By synthesizing these insights, this review underscores the potential of non-invasive diagnostic methods to support clinical decision making and improve asymptomatic patient outcomes by reducing the risk of perioperative ischemic neurological events and preventing further cognitive decline.
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Affiliation(s)
- Balázs Lengyel
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Rita Magyar-Stang
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Hanga Pál
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Róbert Debreczeni
- Department of Neurology, Semmelweis University, 1085 Budapest, Hungary; (R.M.-S.); (H.P.); (R.D.)
- Szentágothai Doctoral School of Neurosciences, Semmelweis University, 1085 Budapest, Hungary
| | - Ágnes Dóra Sándor
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Andrea Székely
- Department of Anesthesiology and Intensive Therapy, Semmelweis University, 1085 Budapest, Hungary; (Á.D.S.); (A.S.)
| | - Dániel Gyürki
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Benjamin Csippa
- Department of Hydrodynamic Systems, Faculty of Mechanical Engineering, Budapest University of Technology and Economics, 1085 Budapest, Hungary; (D.G.); (B.C.)
| | - Lilla István
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
| | - Illés Kovács
- Department of Ophthalmology, Semmelweis University, 1085 Budapest, Hungary; (L.I.); (I.K.)
- Department of Ophthalmology, Weill Cornell Medical College, New York, NY 10065, USA
- Department of Clinical Ophthalmology, Faculty of Health Sciences, Semmelweis University, 1085 Budapest, Hungary
| | - Péter Sótonyi
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
| | - Zsuzsanna Mihály
- Department of Vascular and Endovascular Surgery, Heart and Vascular Center, Semmelweis University, 1122 Budapest, Hungary; (B.L.); (P.S.J.)
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9
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Crippa IA, Vincent JL, Zama Cavicchi F, Pozzebon S, Gaspard N, Maenhout C, Creteur J, Taccone FS. Estimated Cerebral Perfusion Pressure and Intracranial Pressure in Septic Patients. Neurocrit Care 2024; 40:577-586. [PMID: 37420137 DOI: 10.1007/s12028-023-01783-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/02/2023] [Accepted: 06/09/2023] [Indexed: 07/09/2023]
Abstract
BACKGROUND Sepsis-associated brain dysfunction (SABD) is frequent and is associated with poor outcome. Changes in brain hemodynamics remain poorly described in this setting. The aim of this study was to investigate the alterations of cerebral perfusion pressure and intracranial pressure in a cohort of septic patients. METHODS We conducted a retrospective analysis of prospectively collected data in septic adults admitted to our intensive care unit (ICU). We included patients in whom transcranial Doppler recording performed within 48 h from diagnosis of sepsis was available. Exclusion criteria were intracranial disease, known vascular stenosis, cardiac arrhythmias, pacemaker, mechanical cardiac support, severe hypotension, and severe hypocapnia or hypercapnia. SABD was clinically diagnosed by the attending physician, anytime during the ICU stay. Estimated cerebral perfusion pressure (eCPP) and estimated intracranial pressure (eICP) were calculated from the blood flow velocity of the middle cerebral artery and invasive arterial pressure using a previously validated formula. Normal eCPP was defined as eCPP ≥ 60 mm Hg, low eCPP was defined as eCPP < 60 mm Hg; normal eICP was defined as eICP ≤ 20 mm Hg, and high eICP was defined as eICP > 20 mm Hg. RESULTS A total of 132 patients were included in the final analysis (71% male, median [interquartile range (IQR)] age was 64 [52-71] years, median [IQR] Acute Physiology and Chronic Health Evaluation II score on admission was 21 [15-28]). Sixty-nine (49%) patients developed SABD during the ICU stay, and 38 (29%) were dead at hospital discharge. Transcranial Doppler recording lasted 9 (IQR 7-12) min. Median (IQR) eCPP was 63 (58-71) mm Hg in the cohort; 44 of 132 (33%) patients had low eCPP. Median (IQR) eICP was 8 (4-13) mm Hg; five (4%) patients had high eICP. SABD occurrence and in-hospital mortality did not differ between patients with normal eCPP and patients with low eCPP or between patients with normal eICP and patients with high eICP. Eighty-six (65%) patients had normal eCPP and normal eICP, 41 (31%) patients had low eCPP and normal eICP, three (2%) patients had low eCPP and high eICP, and two (2%) patients had normal eCPP and high eICP; however, SABD occurrence and in-hospital mortality were not significantly different among these subgroups. CONCLUSIONS Brain hemodynamics, in particular CPP, were altered in one third of critically ill septic patients at a steady state of monitoring performed early during the course of sepsis. However, these alterations were equally common in patients who developed or did not develop SABD during the ICU stay and in patients with favorable or unfavorable outcome.
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Affiliation(s)
- Ilaria Alice Crippa
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium.
- Department of Anesthesiology and Intensive Care, Policlinico San Marco, Gruppo San Donato, Corso Europa 7, 24046, Zingonia, Italy.
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Federica Zama Cavicchi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Selene Pozzebon
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Nicolas Gaspard
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Christelle Maenhout
- Department of Neurology, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik 808, 1070, Brussels, Belgium
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10
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Hanalioglu D, Temkit M'H, Hildebrandt K, MackDiaz E, Goldstein Z, Aggarwal S, Appavu B. Neurophysiologic Features Reflecting Brain Injury During Pediatric ECMO Support. Neurocrit Care 2024; 40:759-768. [PMID: 37697125 PMCID: PMC10959789 DOI: 10.1007/s12028-023-01836-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2023] [Accepted: 08/08/2023] [Indexed: 09/13/2023]
Abstract
BACKGROUND Extracorporeal membrane oxygenation (ECMO) provides lifesaving support to critically ill patients who experience refractory cardiopulmonary failure but carries a high risk for acute brain injury. We aimed to identify characteristics reflecting acute brain injury in children requiring ECMO support. METHODS This is a prospective observational study from 2019 to 2022 of pediatric ECMO patients undergoing neuromonitoring, including continuous electroencephalography, cerebral oximetry, and transcranial Doppler ultrasound (TCD). The primary outcome was acute brain injury. Clinical and neuromonitoring characteristics were collected. Multivariate logistic regression was implemented to model odds ratios (ORs) and identify the combined characteristics that best discriminate risk of acute brain injury using the area under the receiver operating characteristic curve. RESULTS Seventy-five pediatric patients requiring ECMO support were enrolled in this study, and 62 underwent neuroimaging or autopsy evaluations. Of these 62 patients, 19 experienced acute brain injury (30.6%), including seven (36.8%) with arterial ischemic stroke, four (21.1%) with hemorrhagic stroke, seven with hypoxic-ischemic brain injury (36.8%), and one (5.3%) with both arterial ischemic stroke and hypoxic-ischemic brain injury. A univariate analysis demonstrated acute brain injury to be associated with maximum hourly seizure burden (p = 0.021), electroencephalographic suppression percentage (p = 0.022), increased interhemispheric differences in electroencephalographic total power (p = 0.023) and amplitude (p = 0.017), and increased differences in TCD Thrombolysis in Brain Ischemia (TIBI) scores between bilateral middle cerebral arteries (p = 0.023). Best subset model selection identified increased seizure burden (OR = 2.07, partial R2 = 0.48, p = 0.013), increased quantitative electroencephalographic interhemispheric amplitude differences (OR = 2.41, partial R2 = 0.48, p = 0.013), and increased interhemispheric TCD TIBI score differences (OR = 4.66, partial R2 = 0.49, p = 0.006) to be independently associated with acute brain injury (area under the receiver operating characteristic curve = 0.92). CONCLUSIONS Increased seizure burden and increased interhemispheric differences in both quantitative electroencephalographic amplitude and TCD MCA TIBI scores are independently associated with acute brain injury in children undergoing ECMO support.
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Affiliation(s)
- Damla Hanalioglu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - M 'Hamed Temkit
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Kara Hildebrandt
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Elizabeth MackDiaz
- Department of Pediatrics, Medical University of South Carolina, Charleston, SC, USA
| | - Zachary Goldstein
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Shefali Aggarwal
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA
| | - Brian Appavu
- Division of Neurology, Department of Neuroscience, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E Thomas Rd, Phoenix, AZ, 85016, USA.
- Department of Child Health, The University of Arizona College of Medicine - Phoenix, Phoenix, AZ, USA.
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Tabone L, El-Tannoury J, Levy M, Sauthier M, Joram N, Du Pont-Thibodeau G, Bourgoin P, Al-Omar S, Poirier N, Emeriaud G, Thibault C. Determining Optimal Mean Arterial Blood Pressure Based on Cerebral Autoregulation in Children after Cardiac Surgery. Pediatr Cardiol 2024; 45:81-91. [PMID: 37945783 DOI: 10.1007/s00246-023-03326-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/26/2023] [Accepted: 10/10/2023] [Indexed: 11/12/2023]
Abstract
To evaluate the feasibility of continuous determination of the optimal mean arterial blood pressure (opt-MAP) according to cerebral autoregulation and to describe the opt-MAP, the autoregulation limits, and the time spent outside these limits in children within 48 h of cardiac surgery. Cerebral autoregulation was assessed using the correlation coefficient (COx) between cerebral oxygenation and MAP in children following cardiac surgery. Plots depicting the COx according to the MAP were used to determine the opt-MAP using weighted multiple time windows. For each patient, we estimated (1) the time spent with MAP outside the autoregulation limits and (2) the burden of deviation, defined as the area between the MAP curve and the autoregulation limits when the MAP was outside these limits. Fifty-one patients with a median age of 7.1 (IQR 0.7-52.0) months old were included. The opt-MAP was calculated for 94% (IQR 90-96) of the monitored time. The opt-MAP was significantly lower in neonates < 1 month old. The patients spent 24% (18-31) of the time outside of the autoregulation limits, with no significant differences between age groups. Continuous determination of the opt-MAP is feasible in children within the first 48 h following cardiac surgery.
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Affiliation(s)
- Laurence Tabone
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Pediatric Intensive Care Unit and Pediatric Emergency Department, CHU Clocheville, Tours, France
| | - Jihad El-Tannoury
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Michael Levy
- Pediatric Intensive Care Unit, CHU Robert Debré, Paris, France
| | - Michael Sauthier
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Nicolas Joram
- Pediatric Intensive Care Unit, CHU de Nantes, Nantes, France
| | - Geneviève Du Pont-Thibodeau
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Pierre Bourgoin
- Pediatric Intensive Care Unit, CHU de Nantes, Nantes, France
| | - Sally Al-Omar
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Nancy Poirier
- Department of Cardiac Surgery, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Guillaume Emeriaud
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada
| | - Céline Thibault
- Division of Critical Care Medicine, Department of Pediatrics, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
- Research Center, CHU Sainte-Justine, Université de Montréal, Montreal, QC, Canada.
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12
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Appavu B, Dunning E, Hildebrandt K, Hanalioglu D, Abruzzo T. Changes in autonomic function and cerebral and somatic oxygenation with arterial flow pulsatility for children requiring veno-arterial extracorporeal membrane oxygenation. BRAIN & SPINE 2023; 4:102731. [PMID: 38510614 PMCID: PMC10951706 DOI: 10.1016/j.bas.2023.102731] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/14/2023] [Revised: 12/01/2023] [Accepted: 12/08/2023] [Indexed: 03/22/2024]
Abstract
Background Veno-arterial extracorporeal membrane oxygenation (VA-ECMO) carries variability in arterial flow pulsatility (AFP). Research question What changes in cerebral and somatic oxygenation, hemodynamics, and autonomic function are associated with AFP during VA-ECMO? Methods This is a prospective study of children on VA-ECMO undergoing neuromonitoring. AFP was quantified by arterial blood pressure pulse amplitude and subcategorized: no pulsatility (<1 mmHg), minimal pulsatility (1 to <5 mmHg), moderate pulsatility (5 to <15 mmHg) and high pulsatility (≥15 mmHg). CVPR was assessed using the cerebral oximetry index (COx). Cerebral and somatic oxygenation was assessed using cerebral regional oximetry (rSO2) or peripheral oxygen saturation (SpO2). Autonomic function was assessed using baroreflex sensitivity (BRs), low-frequency high-frequency (LF/HF) ratio and standard deviation of heart rate R-R intervals (HRsd). Differences were assessed across AFP categories using linear mixed effects models with Tukey pairwise comparisons. Univariate logistic regression was used to explore risk of AFP with brain injuries. Results Among fifty-three children, comparisons of moderate to high pulsatility were associated with reductions in rSO2 (p < 0.001), SpO 2 (p = 0.005), LF/HF ratio (p = 0.028) and an increase in HRsd (p < 0.001). Reductions in BRs were observed across comparisons of none to minimal (P < 0.001) and minimal to moderate pulsatility (p = 0.004). Comparisons of no to low pulsatility were associated with reductions in BRs (p < 0.001) and ABP (p < 0.001) with increases in SpO2 (p < 0.001) and HR (p < 0.001). Arterial ischemic stroke was associated with higher pulsatility (p = 0.0384). Conclusion During VA-ECMO support, changes toward high AFP are associated with autonomic dysregulation and compromised cerebral and somatic tissue oxygenation.
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Affiliation(s)
- Brian Appavu
- Barrow Neurological Institute at Phoenix Children's Hospital, Department of Neurosciences, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, 85016, USA
| | - Elise Dunning
- Creighton University Health Sciences Campus – Phoenix, 3100 N Central Avenue, Phoenix, AZ, 85012, USA
| | - Kara Hildebrandt
- Barrow Neurological Institute at Phoenix Children's Hospital, Department of Neurosciences, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, 85016, USA
| | - Damla Hanalioglu
- Barrow Neurological Institute at Phoenix Children's Hospital, Department of Neurosciences, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, 85016, USA
| | - Todd Abruzzo
- Phoenix Children's Hospital, Department of Radiology, 1919 E. Thomas Road, Phoenix, AZ, 85016, USA
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13
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Kahl U, Krause L, Amin S, Harler U, Beck S, Dohrmann T, Mewes C, Graefen M, Haese A, Zöllner C, Fischer M. Impact of Intraoperative Fluctuations of Cardiac Output on Cerebrovascular Autoregulation: An Integrative Secondary Analysis of Individual-level Data. J Neurosurg Anesthesiol 2023:00008506-990000000-00087. [PMID: 38011867 DOI: 10.1097/ana.0000000000000944] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/18/2023] [Accepted: 10/09/2023] [Indexed: 11/29/2023]
Abstract
BACKGROUND Intraoperative impairment of cerebral autoregulation (CA) has been associated with perioperative neurocognitive disorders. We investigated whether intraoperative fluctuations in cardiac index are associated with changes in CA. METHODS We conducted an integrative explorative secondary analysis of individual-level data from 2 prospective observational studies including patients scheduled for radical prostatectomy. We assessed cardiac index by pulse contour analysis and CA as the cerebral oxygenation index (COx) based on near-infrared spectroscopy. We analyzed (1) the cross-correlation between cardiac index and COx, (2) the correlation between the time-weighted average (TWA) of the cardiac index below 2.5 L min-1 m-2, and the TWA of COx above 0.3, and (3) the difference in areas between the cardiac index curve and the COx curve among various subgroups. RESULTS The final analysis included 155 patients. The median cardiac index was 3.16 [IQR: 2.65, 3.72] L min-1 m-2. Median COx was 0.23 [IQR: 0.12, 0.34]. (1) The median cross-correlation between cardiac index and COx was 0.230 [IQR: 0.186, 0.287]. (2) The correlation (Spearman ρ) between TWA of cardiac index below 2.5 L min-1 m-2 and TWA of COx above 0.3 was 0.095 (P=0.239). (3) Areas between the cardiac index curve and the COx curve did not differ significantly among subgroups (<65 vs. ≥65 y, P=0.903; 0 vs. ≥1 cardiovascular risk factors, P=0.518; arterial hypertension vs. none, P=0.822; open vs. robot-assisted radical prostatectomy, P=0.699). CONCLUSIONS We found no meaningful association between intraoperative fluctuations in cardiac index and CA. However, it is possible that a potential association was masked by the influence of anesthesia on CA.
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Affiliation(s)
| | | | | | | | | | | | | | - Markus Graefen
- Martini-Klinik, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander Haese
- Martini-Klinik, Prostate Cancer Center, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
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14
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Becker K. Animal Welfare Aspects in Planning and Conducting Experiments on Rodent Models of Subarachnoid Hemorrhage. Cell Mol Neurobiol 2023; 43:3965-3981. [PMID: 37861870 DOI: 10.1007/s10571-023-01418-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/31/2023] [Accepted: 09/18/2023] [Indexed: 10/21/2023]
Abstract
Subarachnoid hemorrhage is an acute life-threatening cerebrovascular disease with high socio-economic impact. The most frequent cause, the rupture of an intracerebral aneurysm, is accompanied by abrupt changes in intracerebral pressure, cerebral perfusion pressure and, consequently, cerebral blood flow. As aneurysms rupture spontaneously, monitoring of these parameters in patients is only possible with a time delay, upon hospitalization. To study alterations in cerebral perfusion immediately upon ictus, animal models are mandatory. This article addresses the points necessarily to be included in an animal project proposal according to EU directive 2010/63/EU for the protection of animals used for scientific purposes and herewith offers an insight into animal welfare aspects of using rodent models for the investigation of cerebral perfusion after subarachnoid hemorrhage. It compares surgeries, model characteristics, advantages, and drawbacks of the most-frequently used rodent models-the endovascular perforation model and the prechiasmatic and single or double cisterna magna injection model. The topics of discussing anesthesia, advice on peri- and postanesthetic handling of animals, assessing the severity of suffering the animals undergo during the procedure according to EU directive 2010/63/EU and weighing the use of these in vivo models for experimental research ethically are also presented. In conclusion, rodent models of subarachnoid hemorrhage display pathophysiological characteristics, including changes of cerebral perfusion similar to the clinical situation, rendering the models suited to study the sequelae of the bleeding. A current problem is low standardization of the models, wherefore reporting according to the ARRIVE guidelines is highly recommended. Animal welfare aspects of rodent models of subarachnoid hemorrhage. Rodent models for investigation of cerebral perfusion after subarachnoid hemorrhage are compared regarding surgeries and model characteristics, and 3R measures are suggested. Anesthesia is discussed, and advice given on peri- and postanesthetic handling. Severity of suffering according to 2010/63/EU is assessed and use of these in vivo models weighed ethically.
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Affiliation(s)
- Katrin Becker
- Institute for Translational Neurosurgery, Medical Faculty, RWTH Aachen University, 52074, Aachen, Germany.
- Institute for Cardiovascular Sciences, University Hospital Bonn, 53127, Bonn, Germany.
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15
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Xu J, Li H, Jin G, Zhuang W, Bai Z, Sun J, Chen M, Wang F, Yang X, Qin M. Conductivity reactivity index for monitoring of cerebrovascular autoregulation in early cerebral ischemic rabbits. Biomed Eng Online 2023; 22:78. [PMID: 37559130 PMCID: PMC10410901 DOI: 10.1186/s12938-023-01142-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2023] [Accepted: 07/27/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Cerebrovascular autoregulation (CVAR) is the mechanism that maintains constant cerebral blood flow by adjusting the caliber of the cerebral vessels. It is important to have an effective, contactless way to monitor and assess CVAR in patients with ischemia. METHODS The adjustment of cerebral blood flow leads to changes in the conductivity of the whole brain. Here, whole-brain conductivity measured by the magnetic induction phase shift method is a valuable alternative to cerebral blood volume for non-contact assessment of CVAR. Therefore, we proposed the correlation coefficient between spontaneous slow oscillations in arterial blood pressure and the corresponding magnetic induction phase shift as a novel index called the conductivity reactivity index (CRx). In comparison with the intracranial pressure reactivity index (PRx), the feasibility of the conductivity reactivity index to assess CVAR in the early phase of cerebral ischemia has been preliminarily confirmed in animal experiments. RESULTS There was a significant difference in the CRx between the cerebral ischemia group and the control group (p = 0.002). At the same time, there was a significant negative correlation between the CRx and the PRx (r = - 0.642, p = 0.002) after 40 min after ischemia. The Bland-Altman consistency analysis showed that the two indices were linearly related, with a minimal difference and high consistency in the early ischemic period. The sensitivity and specificity of CRx for cerebral ischemia identification were 75% and 20%, respectively, and the area under the ROC curve of CRx was 0.835 (SE = 0.084). CONCLUSION The animal experimental results preliminarily demonstrated that the CRx can be used to monitor CVAR and identify CVAR injury in early ischemic conditions. The CRx has the potential to be used for contactless, global, bedside, and real-time assessment of CVAR of patients with ischemic stroke.
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Affiliation(s)
- Jia Xu
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Haocheng Li
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
- Department of Medical Engineering, General Hospital of Central Theater Command, Wuhan, China
| | - Gui Jin
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Wei Zhuang
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Zelin Bai
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Jian Sun
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Mingsheng Chen
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Feng Wang
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China
| | - Xu Yang
- Department of Medical Service, General Hospital of Central Theater Command, Wuhan, China
| | - Mingxin Qin
- College of Biomedical Engineering, Third Military Medical University (Army Medical University), Chongqing, China.
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16
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Shim Y, Kim J, Kim HS, Oh J, Lee S, Ha EJ. Intracranial Pressure Monitoring for Acute Brain Injured Patients: When, How, What Should We Monitor. Korean J Neurotrauma 2023; 19:149-161. [PMID: 37431379 PMCID: PMC10329885 DOI: 10.13004/kjnt.2023.19.e32] [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: 06/02/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023] Open
Abstract
While there is no level I recommendation for intracranial pressure (ICP) monitoring, it is typically indicated for patients with severe traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score of 3-8 (class II). Even for moderate TBI patients with GCS 9-12, ICP monitoring should be considered for risk of increased ICP. The impact of ICP monitoring on patient outcomes is still not well-established, but recent studies reported a reduction of early mortality (class III) in TBI patients. There is no standard protocol for the application of ICP monitoring. In cases where cerebrospinal fluid drainage is required, an external ventricular drain is commonly used. In other cases, parenchymal ICP monitoring devices are generally employed. Subdural or non-invasive forms are not suitable for ICP monitoring. The mean value of ICP is the parameter recommended for observation in many guidelines. In TBI, values above 22 mmHg are associated with increased mortality. However, recent studies proposed various parameters including cumulative time with ICP above 20 mmHg (pressure-time dose), pressure reactivity index, ICP waveform characteristics (pulse amplitude of ICP, mean ICP wave amplitude), and the compensatory reserve of the brain (reserve-amplitude-pressure), which are useful in predicting patient outcomes and guiding treatment. Further research is required for validation of these parameters compared to simple ICP monitoring.
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Affiliation(s)
- Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jungook Kim
- Gachon University Gil Hospital Regional Trauma Center, Gachon, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University, Incheon, Korea
| | - Jiwoong Oh
- Departments of Neurological Surgery and Critical Care Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Departments of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
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Beqiri E, Smielewski P, Guérin C, Czosnyka M, Robba C, Bjertnæs L, Frisvold SK. Neurological and respiratory effects of lung protective ventilation in acute brain injury patients without lung injury: brain vent, a single centre randomized interventional study. Crit Care 2023; 27:115. [PMID: 36941683 PMCID: PMC10026451 DOI: 10.1186/s13054-023-04383-z] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/30/2022] [Accepted: 02/25/2023] [Indexed: 03/23/2023] Open
Abstract
INTRODUCTION Lung protective ventilation (LPV) comprising low tidal volume (VT) and high positive end-expiratory pressure (PEEP) may compromise cerebral perfusion in acute brain injury (ABI). In patients with ABI, we investigated whether LPV is associated with increased intracranial pressure (ICP) and/or deranged cerebral autoregulation (CA), brain compensatory reserve and oxygenation. METHODS In a prospective, crossover study, 30 intubated ABI patients with normal ICP and no lung injury were randomly assigned to receive low VT [6 ml/kg/predicted (pbw)]/at either low (5 cmH2O) or high PEEP (12 cmH2O). Between each intervention, baseline ventilation (VT 9 ml/kg/pbw and PEEP 5 cmH2O) were resumed. The safety limit for interruption of the intervention was ICP above 22 mmHg for more than 5 min. Airway and transpulmonary pressures were continuously monitored to assess respiratory mechanics. We recorded ICP by using external ventricular drainage or a parenchymal probe. CA and brain compensatory reserve were derived from ICP waveform analysis. RESULTS We included 27 patients (intracerebral haemorrhage, traumatic brain injury, subarachnoid haemorrhage), of whom 6 reached the safety limit, which required interruption of at least one intervention. For those without intervention interruption, the ICP change from baseline to "low VT/low PEEP" and "low VT/high PEEP" were 2.2 mmHg and 2.3 mmHg, respectively, and considered clinically non-relevant. None of the interventions affected CA or oxygenation significantly. Interrupted events were associated with high baseline ICP (p < 0.001), low brain compensatory reserve (p < 0.01) and mechanical power (p < 0.05). The transpulmonary driving pressure was 5 ± 2 cmH2O in both interventions. Partial arterial pressure of carbon dioxide was kept in the range 34-36 mmHg by adjusting the respiratory rate, hence, changes in carbon dioxide were not associated with the increase in ICP. CONCLUSIONS The present study found that most patients did not experience any adverse effects of LPV, neither on ICP nor CA. However, in almost a quarter of patients, the ICP rose above the safety limit for interrupting the interventions. Baseline ICP, brain compensatory reserve, and mechanical power can predict a potentially deleterious effect of LPV and can be used to personalize ventilator settings. Trial registration NCT03278769 . Registered September 12, 2017.
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Affiliation(s)
- Erta Beqiri
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Claude Guérin
- University of Lyon, Lyon, France
- INSERM955, Créteil, France
| | - Marek Czosnyka
- Department of Clinical Neurosciences, Neurosurgery Department, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- IRCCS for Oncology and Neuroscience, Policlinico San Martino, Genoa, Italy
- Department of Surgical Science Diagnostic and Integrated, University of Genova, Genoa, Italy
| | - Lars Bjertnæs
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway
| | - Shirin K Frisvold
- Department of Anaesthesia and Intensive Care, University Hospital of North Norway, Tromsø, Norway.
- Department of Clinical Medicine, UiT the Arctic University of Norway, Tromsø, Norway.
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18
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Suriani I, van Houte J, de Boer EC, van Knippenberg L, Manzari S, Mischi M, Bouwman RA. Carotid Doppler ultrasound for non-invasive haemodynamic monitoring: a narrative review. Physiol Meas 2023; 43. [PMID: 36179705 DOI: 10.1088/1361-6579/ac96cb] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2022] [Accepted: 09/30/2022] [Indexed: 11/11/2022]
Abstract
Objective.Accurate haemodynamic monitoring is the cornerstone in the management of critically ill patients. It guides the optimization of tissue and organ perfusion in order to prevent multiple organ failure. In the past decades, carotid Doppler ultrasound (CDU) has been explored as a non-invasive alternative for long-established invasive haemodynamic monitoring techniques. Considering the large heterogeneity in reported studies, we conducted a review of the literature to clarify the current status of CDU as a haemodynamic monitoring tool.Approach.In this article, firstly an overview is given of the equipment and workflow required to perform a CDU exam in clinical practice, the limitations and technical challenges potentially faced by the CDU sonographer, and the cerebrovascular mechanisms that may influence CDU measurement outcomes. The following chapter describes alternative techniques for non-invasive haemodynamic monitoring, detailing advantages and limitations compared to CDU. Next, a comprehensive review of the literature regarding the use of CDU for haemodynamic monitoring is presented. Furthermore, feasibility aspects, training requirements and technical developments of CDU are addressed.Main results.Based on the outcomes of these studies, we assess the applicability of CDU-derived parameters within three clinical domains (cardiac output, volume status, and fluid responsiveness), and amongst different patient groups. Finally, recommendations are provided to improve the quality and standardization of future research and clinical practice in this field.Significance.Although CDU is not yet interchangeable with invasive 'gold standard' cardiac output monitoring, the present work shows that certain CDU-derived parameters prove promising in the context of functional haemodynamic monitoring.
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Affiliation(s)
- Irene Suriani
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Joris van Houte
- Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
| | - Esmée C de Boer
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Luuk van Knippenberg
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - Sabina Manzari
- Philips Research High Tech Campus 34, 5656 AE Eindhoven, The Netherlands
| | - Massimo Mischi
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands
| | - R Arthur Bouwman
- Eindhoven University of Technology, Groene Loper 3, 5612 AE Eindhoven, The Netherlands.,Catharina Hospital Michelangelolaan 2, 5623 EJ Eindhoven, The Netherlands
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Warner L, Bach-Hagemann A, Schmidt TP, Pinkernell S, Schubert GA, Clusmann H, Albanna W, Lindauer U, Conzen-Dilger C. Opening a window to the acutely injured brain: Simultaneous retinal and cerebral vascular monitoring in rats. Front Mol Neurosci 2023; 16:1116841. [PMID: 37033376 PMCID: PMC10079937 DOI: 10.3389/fnmol.2023.1116841] [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: 12/05/2022] [Accepted: 02/23/2023] [Indexed: 04/11/2023] Open
Abstract
Many recent research projects have described typical chronic changes in the retinal vasculature for diverse neurovascular and neurodegenerative disorders such as stroke or Alzheimer's disease. Unlike cerebral vasculature, retinal blood vessels can be assessed non-invasively by retinal vessel analysis. To date, there is only a little information about potential simultaneous reactions of retinal and cerebral vessels in acute neurovascular diseases. The field of applications of retinal assessment could significantly be widened if more information about potential correlations between those two vascular beds and the feasibility of non-invasive retinal vessel analysis in acute neurovascular disease were available. Here, we present our protocol for the simultaneous assessment of retinal and cerebral vessels in an acute setting in anesthetized rats using a non-invasive retinal vessel analyzer and a superficial tissue imaging system for laser speckle contrast analysis via a closed bone window. We describe the experimental set-up in detail, outline the pitfalls of repeated retinal vessel analyses in an experimental set-up of several hours, and address issues that arise from the simultaneous use of two different assessment tools. Finally, we demonstrate the robustness and variability of the reactivity of retinal vessels to hypercapnia at baseline as well as their reproducibility over time using two anesthetic protocols common for neurovascular research. In summary, the procedures described in this protocol allow us to directly compare retinal and cerebral vascular beds and help to substantiate the role of the retina as a "window to the brain."
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Affiliation(s)
- Laura Warner
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Annika Bach-Hagemann
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Fraunhofer Institute for Toxicology and Experimental Medicine, Department of Preclinical Pharmacology and Toxicology, Hannover, Germany
| | - Tobias P. Schmidt
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Sarah Pinkernell
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Gerrit A. Schubert
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Hans Clusmann
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Institute for Neurophysiology, University of Cologne, Cologne, Germany
| | - Ute Lindauer
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen-Dilger
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- *Correspondence: Catharina Conzen-Dilger
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Becker S, Klein F, König K, Mathys C, Liman T, Witt K. Assessment of dynamic cerebral autoregulation in near-infrared spectroscopy using short channels: A feasibility study in acute ischemic stroke patients. Front Neurol 2022; 13:1028864. [PMID: 36479048 PMCID: PMC9719939 DOI: 10.3389/fneur.2022.1028864] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/26/2022] [Accepted: 11/04/2022] [Indexed: 10/07/2023] Open
Abstract
Introduction In acute ischemic stroke, progressive impairment of cerebral autoregulation (CA) is frequent and associated with unfavorable outcomes. Easy assessment of cerebral blood flow and CA in stroke units bedside tools like near-infrared spectroscopy (NIRS) might improve early detection of CA deterioration. This study aimed to assess dynamic CA with multichannel CW-NIRS in acute ischemic stroke (AIS) patients compared to agematched healthy controls. Methods CA reaction was amplified by changes in head of bed position. Long- and short channels were used to monitor systemic artery pressure- and intracranial oscillations simultaneously. Gain and phase shift in spontaneous low- and very low-frequency oscillations (LFO, VLFO) of blood pressure were assessed. Results A total of 54 participants, 27 with AIS and 27 age-matched controls were included. Gain was significantly lower in the AIS group in the LFO range (i) when the upper body was steadily elevated to 30. and (ii) after its abrupt elevation to 30°. No other differences were found between groups. Discussion This study demonstrates the feasibility of NIRS short channels to measure CA in AIS patients in one single instrument. A lower gain in AIS might indicate decreased CA activity in this pilot study, but further studies investigating the role of NIRS short channels in AIS are needed.
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Affiliation(s)
- Sabeth Becker
- Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Franziska Klein
- Neurocognition and Functional Neurorehabilitation Group, Neuropsychology Lab, Department of Psychology, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Katja König
- Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
- University Clinic for Neurology, Evangelical Hospital, Oldenburg, Germany
| | - Christian Mathys
- Institute of Radiology and Neuroradiology, Evangelical Hospital, Oldenburg, Germany
- Research Centre Neurosensory Science, Department of Human Medicine, Faculty of Medicine and Health Sciences, University of Oldenburg, Oldenburg, Germany
| | - Thomas Liman
- Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
- University Clinic for Neurology, Evangelical Hospital, Oldenburg, Germany
| | - Karsten Witt
- Department of Neurology, School of Medicine and Health Sciences, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
- University Clinic for Neurology, Evangelical Hospital, Oldenburg, Germany
- Institute of Radiology and Neuroradiology, Evangelical Hospital, Oldenburg, Germany
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Intracranial Pressure Monitoring and Management. Neurocrit Care 2022. [DOI: 10.1017/9781108907682.002] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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22
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Papanikolaou J, Karelas D, Kutsogiannis DJ, Platogiannis N, Karakitsos D. An underestimated tool for both cooling and circulatory support in cardiac arrest survivors developing severe hyperthermia. Resusc Plus 2022; 10:100224. [PMID: 35403070 PMCID: PMC8983430 DOI: 10.1016/j.resplu.2022.100224] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Revised: 03/09/2022] [Accepted: 03/12/2022] [Indexed: 10/28/2022] Open
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He E, Liu M, Gong S, Fu X, Han Y, Deng F. White Matter Alterations in Depressive Disorder. Front Immunol 2022; 13:826812. [PMID: 35634314 PMCID: PMC9133348 DOI: 10.3389/fimmu.2022.826812] [Citation(s) in RCA: 9] [Impact Index Per Article: 4.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2021] [Accepted: 03/22/2022] [Indexed: 11/13/2022] Open
Abstract
Depressive disorder is the most prevalent affective disorder today. Depressive disorder has been linked to changes in the white matter. White matter changes in depressive disorder could be a result of impaired cerebral blood flow (CBF) and CBF self-regulation, impaired blood-brain barrier function, inflammatory factors, genes and environmental factors. Additionally, white matter changes in patients with depression are associated with clinical variables such as differential diagnosis, severity, treatment effect, and efficacy assessment. This review discusses the characteristics, possible mechanisms, clinical relevance, and potential treatment of white matter alterations caused by depressive disorders.
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Liu M, He E, Fu X, Gong S, Han Y, Deng F. Cerebral blood flow self-regulation in depression. J Affect Disord 2022; 302:324-331. [PMID: 35032508 DOI: 10.1016/j.jad.2022.01.057] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 10/29/2021] [Revised: 12/21/2021] [Accepted: 01/11/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Depression is a common neuropsychiatric disease with a high prevalence rate. Sleep problems, memory decline, dizziness and headaches are the most common neurological symptoms in depressed patients. Abnormality of cerebral blood flow (CBF) has been observed in depressive patients, but those patients did not have intracranial structural damage. Both of those phenomena might be related to cerebral blood flow self-regulation (CBFSR: cerebral blood flow self-regulation). CBFSR can maintain CBF relatively stable in response to changes in neurological and metabolic factors. Therefore, this review aimed to discuss CBFSR in depression. METHODS We searched for keywords such as "depression", "cerebral blood flow", "cerebral autoregulation", "cerebrovascular reactivity" and the words related to depression. We analyzed whether there is a change in the CBFSR in depression, further explored whether there is a relationship between the pathogenesis of depression and the CBFSR, and discussed the possible mechanism of impaired CBFSR in patients with depression. RESULTS Discovered by the literature review, CBFSR is significantly impaired in depressed patients. The level of circulating markers of endothelial dysfunction, nitric oxide, inflammatory cytokines, glucocorticoid and monoamine neurotransmitters is mostly abnormal in depression, which affected the CBFSR to varying degrees. LIMITATIONS Limitations include the small number of direct studies about depression and CBFSR mechanisms. CONCLUSION CBFSR is impaired in depression. The underlying mechanisms include endothelial dysfunction, overactivation of microglia and changes of cytokines, hyperactivation of the HPA axis, increased oxidative stress, monoamine neurotransmitter disorders, etc. These deepened our understanding of the clinical symptoms of depressed patients.
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Affiliation(s)
- Min Liu
- Department of Neurology, The First Hospital of Jilin University, No.1, Xinmin Street, Changchun, China
| | - Enling He
- Department of Neurology, The First Hospital of Jilin University, No.1, Xinmin Street, Changchun, China
| | - Xiyao Fu
- Department of Neurology, The First Hospital of Jilin University, No.1, Xinmin Street, Changchun, China
| | - Sizhu Gong
- Department of Neurology, The First Hospital of Jilin University, No.1, Xinmin Street, Changchun, China
| | - Yue Han
- Department of Neurology, The First Hospital of Jilin University, No.1, Xinmin Street, Changchun, China
| | - Fang Deng
- Department of Neurology, The First Hospital of Jilin University, No.1, Xinmin Street, Changchun, China.
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Optic Nerve Sheath Diameter Ultrasound: A Non-Invasive Approach to Evaluate Increased Intracranial Pressure in Critically Ill Pediatric Patients. Diagnostics (Basel) 2022; 12:diagnostics12030767. [PMID: 35328319 PMCID: PMC8946972 DOI: 10.3390/diagnostics12030767] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2022] [Revised: 03/15/2022] [Accepted: 03/15/2022] [Indexed: 01/16/2023] Open
Abstract
Early diagnosis of increased intracranial pressure (ICP) is crucial for prompt diagnosis and treatment of intracranial hypertension in critically ill pediatric patients, preventing secondary brain damage and mortality. Although the placement of an external ventricular drain coupled to an external fluid-filled transducer remains the gold standard for continuous ICP monitoring, other non-invasive approaches are constantly being improved and can provide reliable estimates. The use of point-of-care ultrasound (POCUS) for the assessment of ICP has recently become widespread in pediatric emergency and critical care settings, representing a valuable extension of the physical examination. The aim of this manuscript is to review and discuss the basic principles of ultra-sound measurement of the optic nerve sheath diameter (ONSD) and summarize current evidence on its diagnostic value in pediatric patients with ICP. There is increasing evidence that POCUS measurement of the ONSD correlates with ICP, thus appearing as a useful extension of the physical examination in pediatrics, especially in emergency medicine and critical care settings for the initial non-invasive assessment of patients with suspected raised ICP. Its role could be of value even to assess the response to therapy and in the follow-up of patients with diagnosed intracranial hypertension if invasive ICP monitoring is not available. Further studies on more homogeneous and extensive study populations should be performed to establish ONSD reference ranges in the different pediatric ages and to define cut-off values in predicting elevated ICP compared to invasive ICP measurement.
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Fan JL, Nogueira RC, Brassard P, Rickards CA, Page M, Nasr N, Tzeng YC. Integrative physiological assessment of cerebral hemodynamics and metabolism in acute ischemic stroke. J Cereb Blood Flow Metab 2022; 42:454-470. [PMID: 34304623 PMCID: PMC8985442 DOI: 10.1177/0271678x211033732] [Citation(s) in RCA: 11] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022]
Abstract
Restoring perfusion to ischemic tissue is the primary goal of acute ischemic stroke care, yet only a small portion of patients receive reperfusion treatment. Since blood pressure (BP) is an important determinant of cerebral perfusion, effective BP management could facilitate reperfusion. But how BP should be managed in very early phase of ischemic stroke remains a contentious issue, due to the lack of clear evidence. Given the complex relationship between BP and cerebral blood flow (CBF)-termed cerebral autoregulation (CA)-bedside monitoring of cerebral perfusion and oxygenation could help guide BP management, thereby improve stroke patient outcome. The aim of INFOMATAS is to 'identify novel therapeutic targets for treatment and management in acute ischemic stroke'. In this review, we identify novel physiological parameters which could be used to guide BP management in acute stroke, and explore methodologies for monitoring them at the bedside. We outline the challenges in translating these potential prognostic markers into clinical use.
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Affiliation(s)
- Jui-Lin Fan
- Manaaki Mānawa - The Centre for Heart Research, Department of Physiology, Faculty of Medical & Health Sciences, University of Auckland, Auckland, New Zealand
| | - Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Neurology Department, Hospital Nove de Julho, São Paulo, Brazil
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec, Canada
| | - Caroline A Rickards
- Department of Physiology & Anatomy, University of North Texas Health Science Center, Fort Worth, TX, USA
| | - Matthew Page
- Department of Radiology, Wellington Regional Hospital, Wellington, New Zealand
| | - Nathalie Nasr
- Department of Neurology, Toulouse University Hospital, NSERM UMR 1297, Toulouse, France
| | - Yu-Chieh Tzeng
- Wellington Medical Technology Group, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand.,Centre for Translational Physiology, Department of Surgery & Anaesthesia, University of Otago, Wellington, New Zealand
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Washio T, Watanabe H, Suzuki K, Saito S, Ogoh S. Site-specific different dynamic cerebral autoregulation and cerebrovascular response to carbon dioxide in posterior cerebral circulation during isometric exercise in healthy young men. Auton Neurosci 2022; 238:102943. [PMID: 35086019 DOI: 10.1016/j.autneu.2022.102943] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/16/2021] [Accepted: 01/16/2022] [Indexed: 11/23/2022]
Abstract
Different cerebral blood flow (CBF) responses to exercise between the posterior cerebral artery (PCA) and vertebral artery (VA) have been previously observed, though the physiological mechanisms remain unknown. There is regional heterogeneity in sympathetic innervation between the PCA and VA, which may affect CBF regulation, especially during sympathoexcitation. Thus, in the present study, we hypothesized that different CBF regulatory mechanisms between PCA and VA contribute to heterogeneous CBF responses to isometric exercise. To test this hypothesis, in thirteen healthy young men, dynamic cerebral autoregulation (CA) and cerebrovascular CO2 reactivity (CVR), were identified in each artery during a 2-min isometric handgrip (IHG) exercise at 30% of maximum voluntary contraction. Similar to previous data, PCA cerebrovascular conductance (CVC) index was decreased from rest (P < 0.004), but not VA CVC during IHG exercise (P > 0.084). Dynamic CA in both PCA and VA were unaltered during the IHG exercise (P = 0.129). On the other hand, PCA CVR was increased during the IHG exercise (P < 0.001) while VA CVR was unchanged (P = 0.294). In addition, individual exercise-induced changes in end-tidal partial pressure of CO2 was related to the individual change in PCA blood velocity (P < 0.046), but was not observed for VA blood flow (P > 0.420). Therefore, these exercise-induced differences in CVR between PCA and VA may contribute to exercise-induced heterogeneous CBF response in the posterior cerebral circulation. These findings indicate that the site-specific posterior CBF should be considered in further research for assessing posterior cerebral circulation.
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Affiliation(s)
- Takuro Washio
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan
| | - Hironori Watanabe
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan
| | - Kazuya Suzuki
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan
| | - Shotaro Saito
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan
| | - Shigehiko Ogoh
- Department of Biomedical Engineering, Toyo University, Kawagoe-Shi, Saitama, Japan; Neurovascular Research Laboratory, University of South Wales, UK.
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Warner L, Bach-Hagemann A, Albanna W, Clusmann H, Schubert GA, Lindauer U, Conzen-Dilger C. Vascular Reactivity to Hypercapnia Is Impaired in the Cerebral and Retinal Vasculature in the Acute Phase After Experimental Subarachnoid Hemorrhage. Front Neurol 2022; 12:757050. [PMID: 35095718 PMCID: PMC8793938 DOI: 10.3389/fneur.2021.757050] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/11/2021] [Accepted: 11/22/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Impaired cerebral blood flow (CBF) regulation, such as reduced reactivity to hypercapnia, contributes to the pathophysiology after aneurysmal subarachnoid hemorrhage (SAH), but temporal dynamics in the acute phase are unknown. Featuring comparable molecular regulation mechanisms, the retinal vessels participate in chronic and subacute stroke- and SAH-associated vessel alterations in patients and can be studied non-invasively. This study is aimed to characterize the temporal course of the cerebral and retinal vascular reactivity to hypercapnia in the acute phase after experimental SAH and compare the potential degree of impairment.Methods: Subarachnoid hemorrhage was induced by injecting 0.5 ml of heparinized autologous blood into the cisterna magna of male Wistar rats using two anesthesia protocols [isoflurane/fentanyl n = 25 (Sham + SAH): Iso—Group, ketamine/xylazine n = 32 (Sham + SAH): K/X—Group]. CBF (laser speckle contrast analysis) and physiological parameters were measured continuously for 6 h. At six predefined time points, hypercapnia was induced by hypoventilation controlled via blood gas analysis, and retinal vessel diameter (RVD) was determined non-invasively.Results: Cerebral reactivity and retinal reactivity in Sham groups were stable with only a slight attenuation after 2 h in RVD of the K/X—Group. In the SAH Iso—Group, cerebral and retinal CO2 reactivity compared to baseline was immediately impaired starting at 30 min after SAH (CBF p = 0.0090, RVD p = 0.0135) and lasting up to 4 h (p = 0.0136, resp. p = 0.0263). Similarly, in the K/X—Group, cerebral CO2 reactivity was disturbed early after SAH (30 min, p = 0.003) albeit showing a recovery to baseline after 2 h while retinal CO2 reactivity was impaired over the whole observation period (360 min, p = 0.0001) in the K/X—Group. After normalization to baseline, both vascular beds showed a parallel behavior regarding the temporal course and extent of impairment.Conclusion: This study provides a detailed temporal analysis of impaired cerebral vascular CO2 reactivity starting immediately after SAH and lasting up to 6 h. Importantly, the retinal vessels participate in these acute changes underscoring the promising role of the retina as a potential non-invasive screening tool after SAH. Further studies will be required to determine the correlation with functional outcomes.
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Affiliation(s)
- Laura Warner
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Annika Bach-Hagemann
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Walid Albanna
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Gerrit A. Schubert
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Ute Lindauer
- Translational Neurosurgery and Neurobiology, Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
| | - Catharina Conzen-Dilger
- Department of Neurosurgery, Medical Faculty, RWTH Aachen University, Aachen, Germany
- *Correspondence: Catharina Conzen-Dilger
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Balu R, Fischer M. Posterior Reversible Encephalopathy Syndrome. Stroke 2022. [DOI: 10.1016/b978-0-323-69424-7.00038-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
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30
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Pham T, Fernandez C, Blaney G, Tgavalekos K, Sassaroli A, Cai X, Bibu S, Kornbluth J, Fantini S. Noninvasive Optical Measurements of Dynamic Cerebral Autoregulation by Inducing Oscillatory Cerebral Hemodynamics. Front Neurol 2021; 12:745987. [PMID: 34867729 PMCID: PMC8637213 DOI: 10.3389/fneur.2021.745987] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/23/2021] [Accepted: 10/13/2021] [Indexed: 11/13/2022] Open
Abstract
Objective: Cerebral autoregulation limits the variability of cerebral blood flow (CBF) in the presence of systemic arterial blood pressure (ABP) changes. Monitoring cerebral autoregulation is important in the Neurocritical Care Unit (NCCU) to assess cerebral health. Here, our goal is to identify optimal frequency-domain near-infrared spectroscopy (FD-NIRS) parameters and apply a hemodynamic model of coherent hemodynamics spectroscopy (CHS) to assess cerebral autoregulation in healthy adult subjects and NCCU patients. Methods: In five healthy subjects and three NCCU patients, ABP oscillations at a frequency around 0.065 Hz were induced by cyclic inflation-deflation of pneumatic thigh cuffs. Transfer function analysis based on wavelet transform was performed to measure dynamic relationships between ABP and oscillations in oxy- (O), deoxy- (D), and total- (T) hemoglobin concentrations measured with different FD-NIRS methods. In healthy subjects, we also obtained the dynamic CBF-ABP relationship by using FD-NIRS measurements and the CHS model. In healthy subjects, an interval of hypercapnia was performed to induce cerebral autoregulation impairment. In NCCU patients, the optical measurements of autoregulation were linked to individual clinical diagnoses. Results: In healthy subjects, hypercapnia leads to a more negative phase difference of both O and D oscillations vs. ABP oscillations, which are consistent across different FD-NIRS methods and are highly correlated with a more negative phase difference CBF vs. ABP. In the NCCU, a less negative phase difference of D vs. ABP was observed in one patient as compared to two others, indicating a better autoregulation in that patient. Conclusions: Non-invasive optical measurements of induced phase difference between D and ABP show the strongest sensitivity to cerebral autoregulation. The results from healthy subjects also show that the CHS model, in combination with FD-NIRS, can be applied to measure the CBF-ABP dynamics for a better direct measurement of cerebral autoregulation.
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Affiliation(s)
- Thao Pham
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Cristianne Fernandez
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Giles Blaney
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Kristen Tgavalekos
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Angelo Sassaroli
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
| | - Xuemei Cai
- Department of Neurology, Tufts University School of Medicine, Boston, MA, United States
| | - Steve Bibu
- Department of Neurology, Tufts University School of Medicine, Boston, MA, United States
| | - Joshua Kornbluth
- Department of Neurology, Tufts University School of Medicine, Boston, MA, United States
| | - Sergio Fantini
- Department of Biomedical Engineering, Tufts University, Medford, MA, United States
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van Houte J, Mooi FJ, Montenij LJ, Meijs LPB, Suriani I, Conjaerts BCM, Houterman S, Bouwman AR. Correlation of Carotid Doppler Blood Flow With Invasive Cardiac Output Measurements in Cardiac Surgery Patients. J Cardiothorac Vasc Anesth 2021; 36:1081-1091. [PMID: 34756675 DOI: 10.1053/j.jvca.2021.09.043] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Revised: 09/15/2021] [Accepted: 09/27/2021] [Indexed: 11/11/2022]
Abstract
OBJECTIVE Carotid Doppler ultrasound has been a topic of recent interest, as it may be a promising noninvasive hemodynamic monitoring tool. In this study, the relation between carotid artery blood flow and invasive cardiac output (CO) was evaluated. DESIGN A prospective, observational study. SETTING A single-institution, tertiary referral hospital. PARTICIPANTS Eighteen elective cardiac surgery patients. INTERVENTIONS CO was measured by calibrated pulse contour analysis. Simultaneously, carotid artery pulsed-wave Doppler measurements were obtained in the operating room in three clinical settings: after induction of anesthesia (T1), after a passive leg raise maneuverer (T2), and at the end of surgery (T3). MEASUREMENTS AND MAIN RESULTS Correlation and trending between carotid artery blood flow and invasive CO were evaluated. Furthermore, two Bland-Altman plots were constructed to evaluate the level of agreement between carotid artery-derived CO and invasive CO measurements. Carotid artery blood flow correlated moderately with invasive CO (ρ = 0.67, 95% confidence interval 0.56-0.76, p < 0.05). Concordance between the percentage change of carotid artery blood flow and invasive CO from T1 to T3 was 72%. The level of agreement between carotid artery-derived CO and invasive CO was ±2.29; ±2.57 L/min, with a bias of 0.1; -0.54 L/min, and mean error of 50% and 48%, for the two Bland-Altman analyses, respectively. Intraexamination precision was acceptable. CONCLUSIONS In cardiac surgery patients, carotid artery blood flow correlated moderately with invasive CO measurements. However, the trending ability of carotid artery blood flow was poor, and carotid artery-derived CO tended not to be interchangeable with invasive CO.
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Affiliation(s)
- Joris van Houte
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands; Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands.
| | - Frederik J Mooi
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Leon J Montenij
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands; Department of Intensive Care, Catharina Hospital, Eindhoven, The Netherlands
| | - Loek P B Meijs
- Department of Cardiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Irene Suriani
- Department of Electrical Engineering, Eindhoven University of Technology, Eindhoven, The Netherlands
| | - Bente C M Conjaerts
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
| | - Saskia Houterman
- Department of Education and Research, Catharina Hospital, Eindhoven, The Netherlands
| | - Arthur R Bouwman
- Department of Anesthesiology, Catharina Hospital, Eindhoven, The Netherlands
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Skåre C, Karlsen H, Strand-Amundsen RJ, Eriksen M, Skulberg VM, Sunde K, Tønnessen TI, Olasveengen TM. Cerebral perfusion and metabolism with mean arterial pressure 90 vs. 60 mmHg in a porcine post cardiac arrest model with and without targeted temperature management. Resuscitation 2021; 167:251-260. [PMID: 34166747 DOI: 10.1016/j.resuscitation.2021.06.011] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/28/2021] [Revised: 06/07/2021] [Accepted: 06/17/2021] [Indexed: 12/11/2022]
Abstract
AIM To determine whether targeting a mean arterial pressure of 90 mmHg (MAP90) would yield improved cerebral blood flow and less ischaemia compared to MAP 60 mmHg (MAP60) with and without targeted temperature management at 33 °C (TTM33) in a porcine post-cardiac arrest model. METHODS After 10 min of cardiac arrest, 41 swine of either sex were resuscitated until return of spontaneous circulation (ROSC). They were randomised to TTM33 or no-TTM, and MAP60 or MAP90; yielding four groups. Temperatures were managed with intravasal cooling and blood pressure targets with noradrenaline, vasopressin and nitroprusside, as appropriate. After 30 min of stabilisation, animals were observed for two hours. Cerebral perfusion pressure (CPP), cerebral blood flow (CBF), pressure reactivity index (PRx), brain tissue pCO2 (PbtCO2) and tissue intermediary metabolites were measured continuously and compared using mixed models. RESULTS Animals randomised to MAP90 had higher CPP (p < 0.001 for both no-TTM and TTM33) and CBF (no-TTM, p < 0.03; TH, p < 0.001) compared to MAP60 during the 150 min observational period post-ROSC. We also observed higher lactate and pyruvate in MAP60 irrespective of temperature, but no significant differences in PbtCO2 and lactate/pyruvate-ratio. We found lower PRx (indicating more intact autoregulation) in MAP90 vs. MAP60 (no-TTM, p = 0.04; TTM33, p = 0.03). CONCLUSION In this porcine cardiac arrest model, targeting MAP90 led to better cerebral perfusion and more intact autoregulation, but without clear differences in ischaemic markers, compared to MAP60. INSTITUTIONAL PROTOCOL NUMBER FOTS, id 8442.
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Affiliation(s)
- Christiane Skåre
- Norwegian National Advisory Unit for Prehospital Emergency Care (NAKOS), Oslo, Norway; Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway.
| | - Hilde Karlsen
- Department of Research and Development and Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | | | - Morten Eriksen
- Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | - Vidar M Skulberg
- Institute for Experimental Medical Research, Oslo University Hospital, Oslo, Norway
| | - Kjetil Sunde
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Tor Inge Tønnessen
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
| | - Theresa M Olasveengen
- Department of Anaesthesiology, Oslo University Hospital, Oslo, Norway; Institute of Clinical Medicine, University of Oslo, Oslo, Norway
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Laurikkala J, Aneman A, Peng A, Reinikainen M, Pham P, Jakkula P, Hästbacka J, Wilkman E, Loisa P, Toppila J, Birkelund T, Blennow K, Zetterberg H, Skrifvars MB. Association of deranged cerebrovascular reactivity with brain injury following cardiac arrest: a post-hoc analysis of the COMACARE trial. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:350. [PMID: 34583763 PMCID: PMC8477475 DOI: 10.1186/s13054-021-03764-6] [Citation(s) in RCA: 15] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/02/2021] [Accepted: 09/09/2021] [Indexed: 01/27/2023]
Abstract
BACKGROUND Impaired cerebrovascular reactivity (CVR) is one feature of post cardiac arrest encephalopathy. We studied the incidence and features of CVR by near infrared spectroscopy (NIRS) and associations with outcome and biomarkers of brain injury. METHODS A post-hoc analysis of 120 comatose OHCA patients continuously monitored with NIRS and randomised to low- or high-normal oxygen, carbon dioxide and mean arterial blood pressure (MAP) targets for 48 h. The tissue oximetry index (TOx) generated by the moving correlation coefficient between cerebral tissue oxygenation measured by NIRS and MAP was used as a dynamic index of CVR with TOx > 0 indicating impaired reactivity and TOx > 0.3 used to delineate the lower and upper MAP bounds for disrupted CVR. TOx was analysed in the 0-12, 12-24, 24-48 h time-periods and integrated over 0-48 h. The primary outcome was the association between TOx and six-month functional outcome dichotomised by the cerebral performance category (CPC1-2 good vs. 3-5 poor). Secondary outcomes included associations with MAP bounds for CVR and biomarkers of brain injury. RESULTS In 108 patients with sufficient data to calculate TOx, 76 patients (70%) had impaired CVR and among these, chronic hypertension was more common (58% vs. 31%, p = 0.002). Integrated TOx for 0-48 h was higher in patients with poor outcome than in patients with good outcome (0.89 95% CI [- 1.17 to 2.94] vs. - 2.71 95% CI [- 4.16 to - 1.26], p = 0.05). Patients with poor outcomes had a decreased upper MAP bound of CVR over time (p = 0.001), including the high-normal oxygen (p = 0.002), carbon dioxide (p = 0.012) and MAP (p = 0.001) groups. The MAP range of maintained CVR was narrower in all time intervals and intervention groups (p < 0.05). NfL concentrations were higher in patients with impaired CVR compared to those with intact CVR (43 IQR [15-650] vs 20 IQR [13-199] pg/ml, p = 0.042). CONCLUSION Impaired CVR over 48 h was more common in patients with chronic hypertension and associated with poor outcome. Decreased upper MAP bound and a narrower MAP range for maintained CVR were associated with poor outcome and more severe brain injury assessed with NfL. Trial registration ClinicalTrials.gov, NCT02698917 .
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Affiliation(s)
- Johanna Laurikkala
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland.
| | - Anders Aneman
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia.,Faculty of Medicine, The University of New South Wales, Sydney, Australia.,Faculty of Medicine and Health Sciences, Macquarie University, Sydney, Australia
| | - Alexander Peng
- Intensive Care Unit, Liverpool Hospital, South Western Sydney Local Health District, Sydney, Australia
| | - Matti Reinikainen
- Department of Anaesthesiology and Intensive Care, University of Eastern Finland and Kuopio University Hospital, Kuopio, Finland
| | - Paul Pham
- Dept of Anaesthesia, John Hunter Hospital, Newcastle, NSW, Australia
| | - Pekka Jakkula
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland
| | - Johanna Hästbacka
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland
| | - Erika Wilkman
- Department of Anaesthesiology, Intensive Care and Pain Medicine, University of Helsinki and Helsinki University Hospital, Meilahden SairaalaHaartmaninkatu 4, 000290, Helsinki, Finland
| | - Pekka Loisa
- Department of Intensive Care, Päijät-Häme Central Hospital, Lahti, Finland
| | - Jussi Toppila
- Department of Neurology, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | | | - Kaj Blennow
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden
| | - Henrik Zetterberg
- Department of Psychiatry and Neurochemistry, Institute of Neuroscience and Physiology, The Sahlgrenska Academy at the University of Gothenburg, Mölndal, Sweden.,Clinical Neurochemistry Laboratory, Sahlgrenska University Hospital, Mölndal, Sweden.,DUK Dementia Research Institute at UCL, London, UK.,Department of Neurodegenerative Disease, UCL Institute of Neurology, London, UK
| | - Markus B Skrifvars
- Department of Emergency Care and Services, Helsinki University Hospital and University of Helsinki, Helsinki, Finland
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Ramírez-Guerrero G, Baghetti-Hernández R, Ronco C. Acute Kidney Injury at the Neurocritical Care Unit. Neurocrit Care 2021; 36:640-649. [PMID: 34518967 DOI: 10.1007/s12028-021-01345-7] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/30/2021] [Accepted: 08/30/2021] [Indexed: 11/24/2022]
Abstract
Neurocritical care has advanced substantially in recent decades, allowing doctors to treat patients with more complicated conditions who require a multidisciplinary approach to achieve better clinical outcomes. In neurocritical patients, nonneurological complications such as acute kidney injury (AKI) are independent predictors of worse clinical outcomes. Different research groups have reported an AKI incidence of 11.6% and an incidence of stage 3 AKI, according to the Kidney Disease: Improving Global Outcomes, that requires dialysis of 3% to 12% in neurocritical patients. These patients tend to be younger, have less comorbidity, and have a different risk profile, given the diagnostic and therapeutic procedures they undergo. Trauma-induced AKI, sepsis, sympathetic overstimulation, tubular epitheliopathy, hyperchloremia, use of nephrotoxic drugs, and renal hypoperfusion are some of the causes of AKI in neurocritical patients. AKI is the result of a sum of events, although the mechanisms underlying many of them remain uncertain; however, two important causes that merit mention are direct alteration of the physiological brain-kidney connection and exposure to injury as a result of the specific medical management and well-established therapies that neurocritical patients are subjected to. This review will focus on AKI in neurocritical care patients. Specifically, it will discuss its epidemiology, causes, associated mechanisms, and relationship to the brain-kidney axis. Additionally, the use and risks of extracorporeal therapies in this group of patients will be reviewed.
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Affiliation(s)
- Gonzalo Ramírez-Guerrero
- Critical Care Unit, Carlos Van Buren Hospital, Valparaíso, Chile.
- Dialysis and Renal Transplant Unit, Carlos Van Buren Hospital, Valparaíso, Chile.
- Deparment of Medicine, Universidad de Valparaíso, Valparaíso, Chile.
| | - Romyna Baghetti-Hernández
- Critical Care Unit, Carlos Van Buren Hospital, Valparaíso, Chile
- Deparment of Medicine, Universidad de Valparaíso, Valparaíso, Chile
| | - Claudio Ronco
- Department of Medicine, Università di Padova, Padua, Italy
- Department of Nephrology, Dialysis and Kidney Transplantation, San Bortolo Hospital, Vicenza, Italy
- International Renal Research Institute of Vicenza, Vicenza, Italy
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Abstract
BACKGROUND Circulatory shock is a life-threatening disorder that is associated with high mortality, with a state of systemic and tissue hypoperfusion that can lead to organ failure, including the brain, where altered mental state is often observed. We hypothesized that cerebral autoregulation (CA) is impaired in patients with circulatory shock. METHODS Adult patients with circulatory shock and healthy controls were included. Cerebral blood flow velocity (CBFV, transcranial Doppler ultrasound) and arterial blood pressure (BP, Finometer or intra-arterial line) were continuously recorded during 5 min in both groups. Autoregulation Index (ARI) was estimated from the CBFV response to a step change in BP, derived by transfer function analysis; ARI ≤ 4 was considered impaired CA. The relationship between organ dysfunction, assessed with the Sequential Organ Failure Assessment (SOFA) score and the ARI, was assessed with linear regression. RESULTS Twenty-five shock patients and 28 age-matched healthy volunteers were studied. The mean ± SD SOFA score was 10.8 ± 4.3. Shock patients compared with control subjects had lower ARI values (4.0 ± 2.1 vs. 5.9 ± 1.5, P = 0.001). Impaired CA was more common in shock patients (44.4% vs. 7.1%, P = 0.003). There was a significant inverse relationship between the ARI and the SOFA score (R = -0.63, P = 0.0008). CONCLUSIONS These results suggest that circulatory shock is often associated with impaired CA and that the severity of CA alterations is correlated with the degree of multiple organ failure, reinforcing the need to monitor cerebral hemodynamics in patients with circulatory shock.
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Labrecque L, Smirl JD, Brassard P. Utilization of the repeated squat-stand model for studying the directional sensitivity of the cerebral pressure-flow relationship. J Appl Physiol (1985) 2021; 131:927-936. [PMID: 34264130 DOI: 10.1152/japplphysiol.00269.2021] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/08/2023] Open
Abstract
Hysteresis in the cerebral pressure-flow relationship describes the superior ability of the cerebrovasculature to buffer cerebral blood flow changes when mean arterial pressure (MAP) increases compared with when MAP decreases. This phenomenon can be evaluated by comparing the change in middle cerebral artery mean blood velocity (MCAv) per change in MAP during either acute increases or decreases in MAP induced by repeated squat-stands (RSS). However, no real baseline can be used for this particular protocol as there is no true stable reference point. Herein, we characterized a novel metric using the greatest MAP oscillations induced by RSS without using an independent baseline value and adjusted for time intervals (ΔMCAvT/ΔMAPT). We also examined whether this metric during each RSS transition was comparable between each other over a 5-min period. ΔMCAvT/ΔMAPT was calculated using the minimum to maximum MCAv and MAP for each RSS performed at 0.05 Hz and 0.10 Hz. We compared averaged ΔMCAvT/ΔMAPT during MAP increases and decreases in 74 healthy participants [9 women; 26 (20-74) yr]. ΔMCAvT/ΔMAPT was lower for MAP increases than MAP decreases at 0.10 Hz RSS only (0.91 ± 0.34 vs. 1.01 ± 0.44 cm·s-1/mmHg; P = 0.0013). For both frequency and MAP direction, time during RSS had no effect on ΔMCAvT/ΔMAPT. This novel analytical method supports the use of the RSS model to evaluate the directional sensitivity of the pressure-flow relationship. These results contribute to the importance of considering the direction of MAP changes, depending on the oscillations frequency when evaluating dynamic cerebral autoregulation.NEW & NOTEWORTHY Repeated squat-stand maneuvers are able to examine the directional sensitivity of the cerebral pressure-flow relationship. These maneuvers induce stable physiological cyclic changes where brain blood flow changes with blood pressure increases are buffered more than blood pressure decreases. These results highlight the importance of considering directional blood pressure changes within cerebral autoregulation.
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Affiliation(s)
- Lawrence Labrecque
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
| | - Jonathan D Smirl
- Sport Injury Prevention Research Centre, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Concussion Research Laboratory, Faculty of Health and Exercise Science, University of British Columbia, Kelowna, British Columbia, Canada.,Human Performance Laboratory, Faculty of Kinesiology, University of Calgary, Calgary, Alberta, Canada.,Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada.,Integrated Concussion Research Program, University of Calgary, Calgary, Alberta, Canada.,Alberta Children's Hospital Research Institute, University of Calgary, Calgary, Alberta, Canada.,Libin Cardiovascular Institute of Alberta, University of Calgary, Alberta, Canada
| | - Patrice Brassard
- Department of Kinesiology, Faculty of Medicine, Université Laval, Québec City, Québec, Canada.,Research Center of the Institut Universitaire de Cardiologie et de Pneumologie de Québec, Québec City, Québec, Canada
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Appavu B, Temkit M'H, Foldes S, Burrows BT, Kuwabara M, Jacobson A, Adelson PD. Association of Outcomes with Model-Based Indices of Cerebral Autoregulation After Pediatric Traumatic Brain Injury. Neurocrit Care 2021; 35:640-650. [PMID: 34268644 DOI: 10.1007/s12028-021-01279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We investigated whether model-based indices of cerebral autoregulation (CA) are associated with outcomes after pediatric traumatic brain injury. METHODS This was a retrospective analysis of a prospective clinical database of 56 pediatric patients with traumatic brain injury undergoing intracranial pressure monitoring. CA indices were calculated, including pressure reactivity index (PRx), wavelet pressure reactivity index (wPRx), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Each CA index was used to compute optimal cerebral perfusion pressure (CPP). Time of CPP below lower limit of autoregulation (LLA) or above upper limit of autoregulation (ULA) were computed for each index. Demographic, physiologic, and neuroimaging data were collected. Primary outcome was determined using Pediatric Glasgow Outcome Scale Extended (GOSE-Peds) at 12 months, with higher scores being suggestive of unfavorable outcome. Univariate and multiple linear regression with guided stepwise variable selection was used to find combinations of risk factors that can best explain the variability of GOSE-Peds scores, and the best fit model was applied to the age strata. We hypothesized that higher GOSE-Peds scores were associated with higher CA values and more time below LLA or above ULA for each index. RESULTS At the univariate level, CPP, dose of intracranial hypertension, PRx, PAx, wPRx, RAC, percent time more than ULA derived for PAx, and percent time less than LLA derived for PRx, PAx, wPRx, and RAC were all associated with GOSE-Peds scores. The best subset model selection on all pediatric patients identified that when accounting for CPP, increased dose of intracranial hypertension and percent time less than LLA derived for wPRx were independently associated with higher GOSE-Peds scores. Age stratification of the best fit model identified that in children less than 2 years of age or 8 years of age or more, percent time less than LLA derived for wPRx represented the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and dose of intracranial hypertension. For children 2 years or younger to less than 8 years of age, dose of intracranial hypertension was identified as the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and percent time less than LLA derived for wPRx. CONCLUSIONS Increased dose of intracranial hypertension, PRx, wPRx, PAx, and RAC values and increased percentage time less than LLA based on PRx, wPRx, PAx, and RAC are associated with higher GOSE-Peds scores, suggestive of unfavorable outcome. Reducing intracranial hypertension and maintaining CPP more than LLA based on wPRx may improve outcomes and warrants prospective investigation.
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Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.
| | - M 'Hamed Temkit
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Michael Kuwabara
- Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.,Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - P David Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
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38
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Robba C, Messina A, Battaglini D, Ball L, Brunetti I, Bassetti M, Giacobbe DR, Vena A, Patroniti N, Cecconi M, Matta BF, Liu X, Rocco PRM, Czosnyka M, Pelosi P. Early Effects of Passive Leg-Raising Test, Fluid Challenge, and Norepinephrine on Cerebral Autoregulation and Oxygenation in COVID-19 Critically Ill Patients. Front Neurol 2021; 12:674466. [PMID: 34220684 PMCID: PMC8242251 DOI: 10.3389/fneur.2021.674466] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2021] [Accepted: 04/29/2021] [Indexed: 12/28/2022] Open
Abstract
Background: Coronavirus disease 2019 (COVID-19) patients are at high risk of neurological complications consequent to several factors including persistent hypotension. There is a paucity of data on the effects of therapeutic interventions designed to optimize systemic hemodynamics on cerebral autoregulation (CA) in this group of patients. Methods: Single-center, observational prospective study conducted at San Martino Policlinico Hospital, Genoa, Italy, from October 1 to December 15, 2020. Mechanically ventilated COVID-19 patients, who had at least one episode of hypotension and received a passive leg raising (PLR) test, were included. They were then treated with fluid challenge (FC) and/or norepinephrine (NE), according to patients' clinical conditions, at different moments. The primary outcome was to assess the early effects of PLR test and of FC and NE [when clinically indicated to maintain adequate mean arterial pressure (MAP)] on CA (CA index) measured by transcranial Doppler (TCD). Secondary outcomes were to evaluate the effects of PLR test, FC, and NE on systemic hemodynamic variables, cerebral oxygenation (rSo2), and non-invasive intracranial pressure (nICP). Results: Twenty-three patients were included and underwent PLR test. Of these, 22 patients received FC and 14 were treated with NE. The median age was 62 years (interquartile range = 57-68.5 years), and 78% were male. PLR test led to a low CA index [58% (44-76.3%)]. FC and NE administration resulted in a CA index of 90.8% (74.2-100%) and 100% (100-100%), respectively. After PLR test, nICP based on pulsatility index and nICP based on flow velocity diastolic formula was increased [18.6 (17.7-19.6) vs. 19.3 (18.2-19.8) mm Hg, p = 0.009, and 12.9 (8.5-18) vs. 15 (10.5-19.7) mm Hg, p = 0.001, respectively]. PLR test, FC, and NE resulted in a significant increase in MAP and rSo2. Conclusions: In mechanically ventilated severe COVID-19 patients, PLR test adversely affects CA. An individualized strategy aimed at assessing both the hemodynamic and cerebral needs is warranted in patients at high risk of neurological complications.
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Affiliation(s)
- Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Denise Battaglini
- San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Iole Brunetti
- San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Matteo Bassetti
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Daniele R Giacobbe
- Department of Health Sciences (DISSAL), University of Genoa, Genoa, Italy.,Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Antonio Vena
- Infectious Diseases Unit, San Martino Policlinico Hospital, Genoa, Italy
| | - Nicolo' Patroniti
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
| | - Maurizio Cecconi
- Humanitas Clinical and Research Center-Istituto di Ricovero e Cura a Carattere Scientifico, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Basil F Matta
- Neurocritical Care Unit, Addenbrookes Hospital, Cambridge, United Kingdom
| | - Xiuyun Liu
- Department of Anesthesiology and Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Rio de Janeiro, Brazil
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,San Martino Policlinico Hospital, Istituto di Ricovero e Cura a Carattere Scientifico for Oncology and Neuroscience, Genoa, Italy
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Plateau Waves of Intracranial Pressure: Methods for Automatic Detection and Prediction. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021. [PMID: 33839853 DOI: 10.1007/978-3-030-59436-7_47] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/01/2023]
Abstract
Plateau waves are recurrent phenomena observed in traumatic brain injury (TBI) patients, characterised by an increase in intracranial pressure (ICP) above 40 mmHg combined with an almost zero arterial blood pressure (ABP) variation and, hence, a decrease in cerebral perfusion pressure (CPP). A raised ICP for a long period of time, namely plateau waves, can lead to a secondary brain injury. Due to the impaired cerebral autoregulation mechanism these TBI patients present, they are admitted to neurocritical care units (NCCUs) to be under continuous multimodal monitoring, which allows a correct diagnosis for each patient. Plateau waves can end naturally by activating a vasoconstriction mechanism which decreases the amount of blood available in the brain. Alternatively, the phenomenon can end with therapeutic treatment.In this sense, the present study consists in the development of an algorithm capable of automatically detecting plateau waves using offline data, i.e. data already collected from patients. This creates an extra tool which allows for faster detection of events to assist their identification and final diagnosis. Despite the additional steps that can be included to improve the algorithm, the results show good performance, and thus it may be applied in NCCUs.
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40
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Perry BG, Lucas SJE. The Acute Cardiorespiratory and Cerebrovascular Response to Resistance Exercise. SPORTS MEDICINE-OPEN 2021; 7:36. [PMID: 34046740 PMCID: PMC8160070 DOI: 10.1186/s40798-021-00314-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/24/2020] [Accepted: 03/07/2021] [Indexed: 12/18/2022]
Abstract
Resistance exercise (RE) is a popular modality for the general population and athletes alike, due to the numerous benefits of regular participation. The acute response to dynamic RE is characterised by temporary and bidirectional physiological extremes, not typically seen in continuous aerobic exercise (e.g. cycling) and headlined by phasic perturbations in blood pressure that challenge cerebral blood flow (CBF) regulation. Cerebral autoregulation has been heavily scrutinised over the last decade with new data challenging the effectiveness of this intrinsic flow regulating mechanism, particularly to abrupt changes in blood pressure over the course of seconds (i.e. dynamic cerebral autoregulation), like those observed during RE. Acutely, RE can challenge CBF regulation, resulting in adverse responses (e.g. syncope). Compared with aerobic exercise, RE is relatively understudied, particularly high-intensity dynamic RE with a concurrent Valsalva manoeuvre (VM). However, the VM alone challenges CBF regulation and generates additional complexity when trying to dissociate the mechanisms underpinning the circulatory response to RE. Given the disparate circulatory response between aerobic and RE, primarily the blood pressure profiles, regulation of CBF is ostensibly different. In this review, we summarise current literature and highlight the acute physiological responses to RE, with a focus on the cerebral circulation.
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Affiliation(s)
- Blake G Perry
- School of Health Sciences, Massey University, Wellington, New Zealand.
| | - Samuel J E Lucas
- School of Sport, Exercise and Rehabilitation Sciences & Centre for Human Brain Health, College of Life and Environmental Sciences, University of Birmingham, Birmingham, UK
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Intraoperative impaired cerebrovascular autoregulation and delayed neurocognitive recovery after major oncologic surgery: a secondary analysis of pooled data. J Clin Monit Comput 2021; 36:765-773. [PMID: 33860406 PMCID: PMC9162974 DOI: 10.1007/s10877-021-00706-z] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2021] [Accepted: 04/08/2021] [Indexed: 11/22/2022]
Abstract
Cerebral blood flow is tightly regulated by cerebrovascular autoregulation (CVA), and intraoperative impairment of CVA has been linked with perioperative neurocognitive disorders. We aim to assess whether impairment of CVA during major oncologic surgery is associated with delayed neurocognitive recovery (DNCR) postoperatively. We performed a secondary analysis of prospectively collected data. Patients were included if they had undergone complete pre- and postoperative neuropsychological assessments, continuous intraoperative measurement of CVA, and major oncologic surgery for visceral, urological, or gynecological cancer. Intraoperative CVA was measured using the time-correlation method based on near-infrared-spectroscopy, and DNCR was assessed with a neuropsychological test battery. A decline in cognitive function before hospital discharge compared with a preoperative baseline assessment was defined as DNCR. One hundred ninety-five patients were included in the analysis. The median age of the study population was 65 years (IQR: 60–68); 11 patients (5.6%) were female. Forty-one patients (21.0%) fulfilled the criteria for DNCR in the early postoperative period. We found a significant association between impaired intraoperative CVA and DNCR before hospital discharge (OR = 1.042 [95% CI: 1.005; 1.080], p = 0.028). The type of surgery (radical prostatectomy vs. other major oncologic surgery; OR = 0.269 [95% CI: 0.099; 0.728], p = 0.010) and premedication with midazolam (OR = 3.360 [95% CI: 1.039; 10.870], p = 0.043) were significantly associated with the occurrence of DNCR in the early postoperative period. Intraoperative impairment of CVA is associated with postoperative neurocognitive function early after oncologic surgery. Therefore, intraoperative monitoring of CVA may be a target for neuroprotective interventions. The initial studies were retrospectively registered with primary clinical trial registries recognized by the World Health Organization (ClinicalTrials.gov Identifiers: DRKS00010014, 21.03.2016 and NCT04101006, 24.07.2019).
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Cardiac Output and Cerebral Blood Flow: A Systematic Review of Cardio-Cerebral Coupling. J Neurosurg Anesthesiol 2021; 34:352-363. [PMID: 33782372 DOI: 10.1097/ana.0000000000000768] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
Control of cerebral blood flow (CBF) is crucial to the management of neurocritically ill patients. Small studies which have examined the role of cardiac output (CO) as a determinant of CBF have inconsistently demonstrated evidence of cardio-cerebral coupling. Putative physiological mechanisms underpinning such coupling include changes in arterial blood pressure pulsatility, which would produce vasodilation through increased oscillatory wall-shear-stress and baroreceptor mediated reflex sympatholysis, and changes in venous backpressure which may improve cerebral perfusion pressure. We sought to summarize and contextualize the literature on the relationship between CO and CBF and discuss the implications of cardio-cerebral coupling for neurocritical care. A systematic review of the literature yielded 41 studies; all were of low-quality and at high-risk of bias. Results were heterogenous, with evidence for both corroboration and confutation of a relationship between CO and CBF in both normal and abnormal cerebrovascular states. Common limitations of studies were lack of instantaneous CBF measures with reliance on transcranial Doppler-derived blood flow velocity as a surrogate, inability to control for fluctuations in established determinants of CBF (eg, PaCO2), and direct effects on CBF by the interventions used to alter CO. Currently, the literature is insufficiently robust to confirm an independent relationship between CO and CBF. Hypothetically, the presence of cardio-cerebral coupling would have important implications for clinical practice. Manipulation of CBF could occur without the risks associated with extremes of arterial pressure, potentially improving therapy for those with cerebral ischemia of various etiologies. However, current literature is insufficiently robust to confirm an independent relationship between CO and CBF, and further studies with improved methodology are required before therapeutic interventions can be based on cardio-cerebral coupling.
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Kahl U, Yu Y, Nierhaus A, Frings D, Sensen B, Daubmann A, Kluge S, Fischer M. Cerebrovascular autoregulation and arterial carbon dioxide in patients with acute respiratory distress syndrome: a prospective observational cohort study. Ann Intensive Care 2021; 11:47. [PMID: 33725209 PMCID: PMC7962086 DOI: 10.1186/s13613-021-00831-7] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2020] [Accepted: 03/01/2021] [Indexed: 12/23/2022] Open
Abstract
BACKGROUND Early hypercapnia is common in patients with acute respiratory distress syndrome (ARDS) and is associated with increased mortality. Fluctuations of carbon dioxide have been associated with adverse neurological outcome in patients with severe respiratory failure requiring extracorporeal organ support. The aim of this study was to investigate whether early hypercapnia is associated with impaired cerebrovascular autoregulation during the acute phase of ARDS. METHODS Between December 2018 and November 2019, patients who fulfilled the Berlin criteria for ARDS, were enrolled. Patients with a history of central nervous system disorders, cerebrovascular disease, chronic hypercapnia, or a life expectancy of less than 24 h were excluded from study participation. During the acute phase of ARDS, cerebrovascular autoregulation was measured over two time periods for at least 60 min. Based on the values of mean arterial blood pressure and near-infrared spectroscopy, a cerebral autoregulation index (COx) was calculated. The time with impaired cerebral autoregulation was calculated for each measurement and was compared between patients with and without early hypercapnia [defined as an arterial partial pressure of carbon dioxide (PaCO2) ≥ 50 mmHg with a corresponding arterial pH < 7.35 within the first 24 h of ARDS diagnosis]. RESULTS Of 66 patients included, 117 monitoring episodes were available. The mean age of the study population was 58.5 ± 16 years. 10 patients (15.2%) had mild, 28 (42.4%) moderate, and 28 (42.4%) severe ARDS. Nineteen patients (28.8%) required extracorporeal membrane oxygenation. Early hypercapnia was present in 39 patients (59.1%). Multivariable analysis did not show a significant association between early hypercapnia and impaired cerebrovascular autoregulation (B = 0.023 [95% CI - 0.054; 0.100], p = 0.556). Hypocapnia during the monitoring period was significantly associated with impaired cerebrovascular autoregulation [B = 0.155 (95% CI 0.014; 0.296), p = 0.032]. CONCLUSION Our results suggest that moderate permissive hypercapnia during the acute phase of ARDS has no adverse effect on cerebrovascular autoregulation and may be tolerated to a certain extent to achieve low tidal volumes. In contrast, episodes of hypocapnia may compromise cerebral blood flow regulation. Trial registration ClinicalTrials.gov; registration number: NCT03949738; date of registration: May 14, 2019.
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Affiliation(s)
- Ursula Kahl
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Yuanyuan Yu
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany
| | - Axel Nierhaus
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Frings
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Barbara Sensen
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anne Daubmann
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Anesthesiology, University Medical Center Hamburg-Eppendorf, Martinistrasse 52, 20246, Hamburg, Germany.
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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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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Fernandes MV, Rosso Melo M, Mowry FE, Lucera GM, Lauar MR, Frigieri G, Biancardi VC, Menani JV, Colombari DSA, Colombari E. Intracranial Pressure During the Development of Renovascular Hypertension. Hypertension 2021; 77:1311-1322. [PMID: 33689460 DOI: 10.1161/hypertensionaha.120.16217] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
[Figure: see text].
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Affiliation(s)
- Marcos Vinicius Fernandes
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Mariana Rosso Melo
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Francesca Elisabeth Mowry
- Department of Anatomy, Physiology, and Pharmacology, College of Veterinary Medicine (F.E.M., V.C.B.), Auburn University, AL.,Center for Neurosciences Research Initiative (F.E.M., V.C.B.), Auburn University, AL
| | - Gabriela Maria Lucera
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Mariana Ruiz Lauar
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Gustavo Frigieri
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Vinicia Campana Biancardi
- Department of Anatomy, Physiology, and Pharmacology, College of Veterinary Medicine (F.E.M., V.C.B.), Auburn University, AL.,Center for Neurosciences Research Initiative (F.E.M., V.C.B.), Auburn University, AL
| | - Jose V Menani
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Débora Simões Almeida Colombari
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
| | - Eduardo Colombari
- From the Department of Physiology and Pathology, School of Dentistry of Araraquara, São Paulo State University, Araraquara, Brazil (M.V.F.S., M.R.M., G.M.L., M.R.L., G.F., J.V.M., D.S.A.C., E.C.)
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Neurological Critical Care: The Evolution of Cerebrovascular Critical Care. Crit Care Med 2021; 49:881-900. [PMID: 33653976 DOI: 10.1097/ccm.0000000000004933] [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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Li W, Zhang M, Huo C, Xu G, Chen W, Wang D, Li Z. Time-evolving coupling functions for evaluating the interaction between cerebral oxyhemoglobin and arterial blood pressure with hypertension. Med Phys 2021; 48:2027-2037. [PMID: 33253413 DOI: 10.1002/mp.14627] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2020] [Revised: 10/21/2020] [Accepted: 11/19/2020] [Indexed: 11/08/2022] Open
Abstract
PURPOSES This study aimed to investigate the network coupling between arterial blood pressure (ABP) and changes in cerebral oxyhemoglobin concentration (Δ [O2 Hb]/Δ [HHb]) oscillations based on dynamical Bayesian inference in hypertensive subjects. METHODS Two groups of subjects, consisting of 30 healthy (Group Control, 55.1 ± 10.6 y), and 32 hypertensive individuals (Group AH, 58.9 ± 8.7 y), participated in this study. A functional near-infrared spectroscopy system was used to measure the Δ [O2 Hb] and Δ [HHb] signals in the bilateral prefrontal cortex (LPFC/RPFC), motor cortex (LMC/RMC), and occipital lobe (LOL/ROL) during the resting state (12 min). Based on continuous wavelet analysis and coupling functions, the directed coupling strength (CS) between ABP and cerebral hemoglobin was identified and analyzed in three frequency intervals (I: 0.6-2 Hz, II: 0.145-0.6 Hz, III: 0.01-0.08 Hz). The Pearson correlations between the CS and blood pressure parameters were calculated in the hypertension group. RESULTS In interval I, Group AH exhibited a significantly higher CS for the coupling from ABP to Δ [O2 Hb] than Group Control in LMC, RMC, LOL, and ROL. In interval III, the CS from ABP to Δ [O2 Hb] in LPFC, RPFC, LMC, RMC, LOL, and ROL was significantly higher in Group AH than in Group Control. For the patients with hypertension, diastolic blood pressure was negatively and pulse pressure was positively related to the CS from ABP to Δ [O2 Hb] oscillations in interval III. CONCLUSIONS The higher CS from ABP to Δ [O2 Hb] in interval I indicated that the components of cardiac activity in cerebral hemoglobin oscillations were more directly responsive to the changes in systematic ABP in patients with hypertension than in healthy subjects. Meanwhile, the higher CS from ABP to Δ [O2 Hb] in interval III indicated that the cerebral hemoglobin oscillations were susceptible to changes in blood pressure in hypertensive subjects. The results may serve as evidence of impairment in cerebral autoregulation after hypertension. The Pearson correlation results showed that diastolic blood pressure and pulse pressure might be regarded as predictors of cerebral autoregulation function in patients with hypertension, and may be useful for hypertension stratification. This study provides novel insights into the interaction mechanism between ABP and cerebral hemodynamics and could help in the development of new assessment techniques for cerebral vascular disease.
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Affiliation(s)
- Wenhao Li
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China.,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, 100083, China
| | - Ming Zhang
- Interdisciplinary Division of Biomedical Engineering, Faculty of Engineering, The Hong Kong Polytechnic University, Kowloon, Hong Kong, China
| | - Congcong Huo
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China.,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, 100083, China
| | - Gongcheng Xu
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China.,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, 100083, China
| | - Wei Chen
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing, 100176, China.,Key Laboratory of Neuro-functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, 100176, China
| | - Daifa Wang
- Key Laboratory for Biomechanics and Mechanobiology of Ministry of Education, School of Biological Science and Medical Engineering, Beihang University, Beijing, 100191, China.,Beijing Advanced Innovation Center for Biomedical Engineering, Beihang University, Beijing, 100083, China
| | - Zengyong Li
- Beijing Key Laboratory of Rehabilitation Technical Aids for Old-Age Disability, National Research Center for Rehabilitation Technical Aids, Beijing, 100176, China.,Key Laboratory of Neuro-functional Information and Rehabilitation Engineering of the Ministry of Civil Affairs, Beijing, 100176, China
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Papasilekas T, Themistoklis KM, Melanis K, Patrikelis P, Spartalis E, Korfias S, Sakas D. A Brief Review of Brain's Blood Flow-Metabolism Coupling and Pressure Autoregulation. J Neurol Surg A Cent Eur Neurosurg 2021; 82:257-261. [PMID: 33583012 DOI: 10.1055/s-0040-1721682] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/22/2022]
Abstract
BACKGROUND The human brain, depending on aerobic glycolysis to cover its metabolic needs and having no energy reserves whatsoever, relies on a constant and closely regulated blood supply to maintain its structural and functional integrity. Cerebral autoregulation, that is, the brain's intrinsic ability to regulate its own blood flow independently from the systemic blood pressure and cardiac output, is an important physiological mechanism that offers protection from hypoperfusion injury. DISCUSSION Two major independent mechanisms are known to be involved in cerebral autoregulation: (1) flow-metabolism coupling and (2) myogenic responses of cerebral blood vessels to changes in transmural/arterial pressure. A third, less prominent component of cerebral autoregulation comes in the form of neurogenic influences on cerebral vasculature. CONCLUSION Although fragmentation of cerebral autoregulation in separate and distinct from each other mechanisms is somewhat arbitrary, such a scheme is useful for reasons of simplification and to better understand their overall effect. Comprehension of cerebral autoregulation is imperative for clinicians in order for them to mitigate consequences of its impairment in the context of traumatic brain injury, subarachnoid hemorrhage, stroke, or other pathological conditions.
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Affiliation(s)
| | | | - Konstantinos Melanis
- Department of Neurology, Evangelismos Athens General Hospital, Athens, Attica, Greece
| | - Panayiotis Patrikelis
- Department of Neurosurgery, Evangelismos Athens General Hospital, Athens, Attica, Greece
| | - Eleftherios Spartalis
- Laboratory of Experimental Surgery and Surgical Research, University of Athens, Athinon, Greece
| | - Stefanos Korfias
- Department of Neurosurgery, Evangelismos Athens General Hospital, Athens, Attica, Greece
| | - Damianos Sakas
- Department of Neurosurgery, Evangelismos Athens General Hospital, Athens, Attica, Greece
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Slessarev M, Mahmoud O, McIntyre CW, Ellis CG. Cerebral Blood Flow Deviations in Critically Ill Patients: Potential Insult Contributing to Ischemic and Hyperemic Injury. Front Med (Lausanne) 2021; 7:615318. [PMID: 33553208 PMCID: PMC7854569 DOI: 10.3389/fmed.2020.615318] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/08/2020] [Accepted: 12/14/2020] [Indexed: 11/27/2022] Open
Abstract
Background: Ischemic and hyperemic injury have emerged as biologic mechanisms that contribute to cognitive impairment in critically ill patients. Spontaneous deviations in cerebral blood flow (CBF) beyond ischemic and hyperemic thresholds may represent an insult that contributes to this brain injury, especially if they accumulate over time and coincide with impaired autoregulation. Methods: We used transcranial Doppler to measure the proportion of time that CBF velocity (CBFv) deviated beyond previously reported ischemic and hyperemic thresholds in a cohort of critically ill patients with respiratory failure and/or shock within 48 h of ICU admission. We also assessed whether these CBFv deviations were more common during periods of impaired dynamic autoregulation, and whether they are explained by concurrent variations in mean arterial pressure (MAP) and end-tidal PCO2 (PetCO2). Results: We enrolled 12 consecutive patients (three females) who were monitored for a mean duration of 462.6 ± 39.8 min. Across patients, CBFv deviated by more than 20–30% from its baseline for 17–24% of the analysis time. These CBFv deviations occurred equally during periods of preserved and impaired autoregulation, while concurrent variations in MAP and PetCO2 explained only 13–21% of these CBFv deviations. Conclusion: CBFv deviations beyond ischemic and hyperemic thresholds are common in critically ill patients with respiratory failure or shock. These deviations occur irrespective of the state of dynamic autoregulation and are not explained by changes in MAP and CO2. Future studies should explore mechanisms responsible for these CBFv deviations and establish whether their cumulative burden predicts poor neurocognitive outcomes.
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Affiliation(s)
- Marat Slessarev
- Department of Medicine, Western University, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada.,Brain & Mind Institute, Western University, London, ON, Canada
| | - Ossama Mahmoud
- Department of Computer Science, Western University, London, ON, Canada
| | - Christopher W McIntyre
- Department of Medicine, Western University, London, ON, Canada.,Department of Medical Biophysics, Western University, London, ON, Canada
| | - Christopher G Ellis
- Department of Medical Biophysics, Western University, London, ON, Canada.,Robarts Research Institute, Western University, London, ON, Canada
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50
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Delay of cerebral autoregulation in traumatic brain injury patients. Clin Neurol Neurosurg 2021; 202:106478. [PMID: 33454499 DOI: 10.1016/j.clineuro.2021.106478] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/07/2020] [Revised: 01/04/2021] [Accepted: 01/05/2021] [Indexed: 11/22/2022]
Abstract
INTRODUCTION Adequate cerebral perfusion prevents secondary insult after traumatic brain injury (TBI). Cerebral autoregulation (CAR) keeps cerebral blood flow (CBF) constant when arterial blood pressure (ABP) changes. Aim of the study was to evaluate the existence of delayed CAR in TBI patients and its possible association with outcome. METHODS We retrospectively analysed TBI patients. Flow velocity (FV) in middle cerebral artery, invasive intra-cranial pressure (ICP) and ABP were recorded. Cerebral perfusion pressure (CPP) was calculated as ABP - ICP. Mean flow index (Mx) > 0.3 defined altered CAR. Samples from patients with altered CAR were further analysed: FV signal was shifted backward relative to CPP; Mx was calculated after each shift (MxD). Mx > 0.3 plus MxD ≤ 0.3 defined delayed CAR. Favourable outcome (FO) at 6 months was defined as Glasgow Outcome Scale 4-5. RESULTS 154 patients were included. GCS was 6 [4-9], ICP was 14 [9-20] mmHg. Data on 6 months outcome were available for 131 patients: 104/131 patients (79 %) were alive; GOS was 4 [3-5]; 70/131 (53 %) had FO. Mx was 0.07 [-0.19 to 0.28] overall. Mx was lower in patients with FO compared others (0.00 [-0.21 to 0.20] vs 0.17 [-0.12 to 0.37], p = 0.02). 118 (77 %) patients had intact CAR and 36 (23 %) patients had altered CAR; 23 patients - 15 % of the general cohort and 64 % of patients with altered CAR - had delayed CAR. Delay in the autoregulatory response was 2 [1-4] seconds. 80/98 (82 %) of patients with intact CAR survived, compared to 16/21 (76 %) with delayed and 8/12 (67 %) with altered CAR (p = 0.20). 80/98 (58 %) patients with intact, 10/21 (48 %) patients with delayed and 3/12 (25 %) patients with altered CAR had FO (p = 0.03). CONCLUSION A subgroup of TBI patients with delayed CAR was identified. Delayed CAR was associated with better neurological outcome than altered CAR.
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