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Fattorello Salimbeni A, Kulyk C, Favruzzo F, De Rosa L, Viaro F, Pieroni A, Mozzetta S, Vosko MR, Baracchini C. Robotic Assisted Transcranial Doppler Monitoring in Acute Neurovascular Care: A Feasibility and Safety Study. Neurocrit Care 2024:10.1007/s12028-024-02121-z. [PMID: 39300038 DOI: 10.1007/s12028-024-02121-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2024] [Accepted: 08/28/2024] [Indexed: 09/22/2024]
Abstract
BACKGROUND Transcranial color Doppler (TCD) is currently the only noninvasive bedside tool capable of providing real-time information on cerebral hemodynamics. However, being operator dependent, TCD monitoring is not feasible in many institutions. Robotic assisted TCD (ra-TCD) was recently developed to overcome these constraints. The aim of this study was to evaluate the safety and feasibility of cerebral monitoring with a novel ra-TCD in acute neurovascular care. METHODS This is a two-center prospective study conducted between August 2021 and February 2022 at Padua University Hospital (Padua, Italy) and Kepler University Hospital (Linz, Austria). Adult patients with conditions impacting cerebral hemodynamics or patients undergoing invasive procedures affecting cerebral hemodynamics were recruited for prolonged monitoring (> 30 min) of the middle cerebral artery with a novel ra-TCD (NovaGuide Intelligent Ultrasound, NeuraSignal, Los Angeles, CA). Manual TCD was also performed for comparison by an experienced operator. Feasibility and safety rates were recorded. RESULTS A total of 92 patients (age: mean 68.5 years, range 36-91; sex: male 57 [62%]) were enrolled in the two centers: 54 in Padua, 38 in Linz. The examination was feasible in the majority of patients (85.9%); the head cradle design and its radiopacity hindered its use during carotid endarterectomy and mechanical thrombectomy. Regarding safety, only one patient (1.1%) reported a minor local edema due to prolonged probe pressure. Velocity values were similar between ra-TCD and manual TCD. CONCLUSIONS This novel ra-TCD showed an excellent safety and feasibility and proved to be as reliable as manual TCD in detecting blood flow velocities. These findings support its wider use for cerebral hemodynamics monitoring in acute neurovascular care. However, further technical improvements are needed to expand the range of applicable settings.
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Affiliation(s)
- Alvise Fattorello Salimbeni
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy.
| | - Caterina Kulyk
- Stroke Unit and Neurosonology Laboratory, Department of Neurology, Kepler University Hospital GmbH, Johannes Kepler University, Linz, Austria
| | - Francesco Favruzzo
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy
| | - Ludovica De Rosa
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy
| | - Federica Viaro
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy
| | - Alessio Pieroni
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy
| | - Stefano Mozzetta
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy
| | - Milan R Vosko
- Stroke Unit and Neurosonology Laboratory, Department of Neurology, Kepler University Hospital GmbH, Johannes Kepler University, Linz, Austria
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Department of Neuroscience, University of Padua School of Medicine, Via Giustiniani 2, Padua, Italy
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Ge J, Qin X, Yu X, Li P, Yao Y, Zhang H, Song H, Liu Z. Amelioration of gait and balance disorders by rosuvastatin is associated with changes in cerebrovascular reactivity in older patients with hypertensive treatment. Hypertens Res 2024; 47:2250-2261. [PMID: 38769134 DOI: 10.1038/s41440-024-01720-9] [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: 11/10/2023] [Revised: 04/19/2024] [Accepted: 04/22/2024] [Indexed: 05/22/2024]
Abstract
To investigate the effect of rosuvastatin on gait and balance disorder progression and elucidate the role of cerebrovascular reactivity (CVR) on this effect. From April 2008 to November 2010, 943 hypertensive patients aged ≥60 years were enrolled from the Shandong area of China. Patients were randomized into rosuvastatin and placebo groups. Gait, balance, CVR, fall and stroke were assessed. During an average 72 months of follow-up, the decreasing trends for step length, step speed, and Berg balance scale scores and the increasing trends for step width and chair rising test were slower in the rosuvastatin group when compared to the placebo group. The hazard ratio of incident balance impairment and falls was 0.542 [95% confidence interval (CI) 0.442-0.663] and 0.532 (95% CI 0.408-0.694), respectively, in the rosuvastatin group compared with placebo group. For CVR progression, the cerebrovascular reserve capacity and breath-holding index were increased and the pulsatility index decreased in the rosuvastatin group, while the cerebrovascular reserve capacity and breath-holding index were decreased, and pulsatility index increased in the placebo group. The changes in gait stability and balance function were independently associated with the changes in the CVR. The odds risks of balance impairment and falls were 2.178 (95% CI: 1.491-3.181) and 3.227 (95% CI: 1.634-6.373), respectively, in the patients with CVR impairment and patients without CVR impairment. Rosuvastatin ameliorated gait and balance disorder progression in older patients with hypertension. This effect might result from the improvement in the CVR. This double-blind clinical trial recruited 943 hypertensive patients aged ≥60 years who were randomly administered rosuvastatin and placebo interventions. The data indicates that rosuvastatin significantly ameliorated the progressions of gait and balance disorders in older hypertensive patients. The cerebrovascular reactivity might play an important mediating role in this amelioration.
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Affiliation(s)
- Junyi Ge
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Xiaofei Qin
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Xinyi Yu
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
- Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China
| | - Peilin Li
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Yanli Yao
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China
| | - Hua Zhang
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China.
- Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China.
| | - Huajing Song
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China.
- Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China.
| | - Zhendong Liu
- Department of Cardiology, Shandong Provincial Hospital Affiliated to Shandong First Medical University, Jinan, Shandong, 250021, China.
- School of Clinical and Basic Medicine, Shandong First Medical University & Shandong Academy of Medical Sciences, Jinan, Shandong, 250117, China.
- Department of ECG Information, Shandong Engineering Research Center, Jinan, Shandong, 250117, China.
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Patel ND, Wainwright MS, Moore A, Suz P, Muangman S, Vavilala MS. Establishing normal Lindegaard Ratio in healthy children 10-16 years of age. Childs Nerv Syst 2024; 40:2829-2833. [PMID: 38907117 DOI: 10.1007/s00381-024-06467-9] [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: 02/09/2024] [Accepted: 05/14/2024] [Indexed: 06/23/2024]
Abstract
PURPOSE Transcranial doppler based diagnostic criteria for cerebral vasospasm are not well established in the pediatric population because there is no published normative data to support the diagnosis. Studies have relied on expert consensus, but the definitions have not been validated in children diagnosed with angiographic evidence of vasospasm. Obtaining normative data is a prerequisite to defining pediatric cerebral vasospasm and the Lindegaard Ratio (LR). In this study, we obtained normative data and calculation of the normal LR from healthy children aged 10-16 years. METHODS TCD and carotid ultrasonography was used to measure steady state velocities of both the middle cerebral artery (VMCA) and the extracranial internal cerebral artery (VEICA) in healthy children aged 10-16 years. Demographic information, hemodynamic characteristics and the calculated LR (VMCA/VEICA) was determined for each subject using descriptive statistics. RESULTS Of the 26 healthy children, 13 were male and 13 were female. VMCA ranged between 53 and 93 cm/sec. LR ranged between 1 and 2.2 for the cohort. VMCA for both males and females were within 2 standard deviations (SD) of the normal mean flow velocity. As the VMCA velocities approached 2 SD above the mean, LR did not exceed 2.2. CONCLUSION Our results help define a threshold for LR which can be used to establish radiographic criteria for cerebral vasospasm in children. Our data suggests that using VMCA criteria alone would overestimate cerebral vasospasm and raises question of whether an LR threshold other than 3 is more appropriate for the cut off between hyperemia versus vasospasm in children.
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Affiliation(s)
- Namrata D Patel
- Department of Neurology, Medical College of Wisconsin, Milwaukee, WI, USA.
| | | | - Anne Moore
- Department of Radiology, University of Washington, Seattle, WA, USA
| | - Pilar Suz
- Department of Anesthesiology, H. Lee Moffit Cancer Center, Tampa, FL, USA
| | - Saipin Muangman
- Department of Anesthesiology, Faculty of Medicine Siriraj Hospital, Mahidol University, Bangkok, Thailand
| | - Monica S Vavilala
- Department of Pediatrics, University of Washington, Seattle, WA, USA
- Department of Anesthesiology, University of Washington, Seattle, WA, USA
- Department of Neurological Surgery, University of Washington, Seattle, WA, USA
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Zhao DX, Caturegli G, Wilcox C, Stephens RS, Kim BS, Keller S, Geocadin RG, Suarez JI, Whitman GJR, Cho SM. Challenges in determining death by neurologic criteria in extracorporeal membrane oxygenation - A single center experience. Perfusion 2024; 39:1238-1246. [PMID: 37387124 PMCID: PMC10756925 DOI: 10.1177/02676591231187548] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/01/2023]
Abstract
INTRODUCTION Apnea test (AT) in patients on extracorporeal membrane oxygenation (ECMO) support is challenging, leading to variation in determining death by neurologic criteria (DNC). We aim to describe the diagnostic criteria and barriers for DNC in adults on ECMO in a tertiary care center. METHODS A retrospective review of a prospective observational standardized neuromonitoring study was conducted in adult VA- and VV-ECMO patients at a tertiary center from June 2016 to March 2022. Brain death was defined according to the 2010 American Academy of Neurology guidelines and following the 2020 World Brain Death Project recommendations for performing AT in ECMO patients. RESULTS Eight (2.7%) ECMO patients (median age = 44 years, 75% male, 50% VA-ECMO) met criteria for DNC, six (75%) of whom were determined with AT. In the other two patients who did not undergo AT due to safety concerns, ancillary tests (transcranial doppler and electroencephalography) were consistent with DNC. An additional seven (2.3%) patients (median age = 55 years, 71% male, 86% VA-ECMO) were noted to have absent brainstem reflexes but failed to complete determination of DNC as they underwent withdrawal of life-sustaining treatment (WLST) before a full evaluation was completed. In these patients, AT was never performed, and ancillary tests were inconsistent with either neurological exam findings and/or neuroimaging supporting DNC, or with each other. CONCLUSION AT was used safely and successfully in 6 of the 8 ECMO patients diagnosed with DNC and was always consistent with the neurological exam and imaging findings, as opposed to ancillary tests alone.
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Affiliation(s)
- David X Zhao
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Giorgio Caturegli
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Christopher Wilcox
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - R. Scott Stephens
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Bo Soo Kim
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Steven Keller
- Division of Pulmonary and Critical Care Medicine, Department of Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Romergryko G. Geocadin
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Jose I. Suarez
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
| | - Glenn JR Whitman
- Cardiovascular Surgery Intensive Care Unit, Department of Surgery, Johns Hopkins Hospital, Baltimore, Maryland
| | - Sung-Min Cho
- Division of Neurosciences Critical Care, Departments of Neurology, Neurosurgery, Anesthesiology and Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, Maryland
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Deana C, Biasucci DG, Aspide R, Brasil S, Vergano M, Leonardis F, Rica E, Cammarota G, Dauri M, Vetrugno G, Longhini F, Maggiore SM, Rasulo F, Vetrugno L. Transcranial Doppler and Color-Coded Doppler Use for Brain Death Determination in Adult Patients: A Pictorial Essay. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2024; 43:979-992. [PMID: 38279568 DOI: 10.1002/jum.16421] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 10/18/2023] [Revised: 01/02/2024] [Accepted: 01/15/2024] [Indexed: 01/28/2024]
Abstract
Transcranial Doppler (TCD) is a repeatable, at-the-bedside, helpful tool for confirming cerebral circulatory arrest (CCA). Despite its variable accuracy, TCD is increasingly used during brain death determination, and it is considered among the optional ancillary tests in several countries. Among its limitations, the need for skilled operators with appropriate knowledge of typical CCA patterns and the lack of adequate acoustic bone windows for intracranial arteries assessment are critical. The purpose of this review is to describe how to evaluate cerebral circulatory arrest in the intensive care unit with TCD and transcranial duplex color-coded doppler (TCCD).
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Affiliation(s)
- Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Daniele G Biasucci
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
| | - Raffaele Aspide
- Anesthesia and Neurointensive Care Unit, Istituto delle Scienze Neurologiche IRCCS, Bologna, Italy
| | - Sergio Brasil
- Neurosurgical Division, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Marco Vergano
- Department of Anesthesia and Intensive Care, San Giovanni Bosco Hospital, Torino, Italy
| | - Francesca Leonardis
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
- Department of Surgical Science, "Tor Vergata" University, Rome, Italy
| | - Ermal Rica
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Gianmaria Cammarota
- Department of Anesthesiology and Intensive Care, Azienda Ospedaliero-Universitaria "Maggiore della Carità", Novara, Italy
- Department of Translational Medicine, Università degli Studi del Piemonte Orientale, Novara, Italy
| | - Mario Dauri
- Department of Clinical Science and Translational Medicine, "Tor Vergata" University, Rome, Italy
- Emergency Department, "Tor Vergata" University Hospital, Rome, Italy
| | - Giuseppe Vetrugno
- Catholic University of the Sacred Heart (UCSC), Rome, Italy
- Risk Management, Fondazione Policlinico Universitario "A. Gemelli" IRCCS, Rome, Italy
| | - Federico Longhini
- Department of Medical and Surgical Sciences, University Hospital Mater Domini, Magna Graecia University, Catanzaro, Italy
| | - Salvatore Maurizio Maggiore
- Department of Innovative Technologies in Medicine & Dentistry, Section of Anesthesia and Intensive Care, "G. D'Annunzio" University, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
| | - Frank Rasulo
- Department of Medical and Surgical Specialties, Radiological Sciences and Public Health, University of Brescia, Brescia, Italy
| | - Luigi Vetrugno
- Department of Anesthesiology, Critical Care Medicine and Emergency, "SS. Annunziata" Hospital, Chieti, Italy
- Department of Medical, Oral and Biotechnological Science, "G. d'Annunzio" Chieti-Pescara University, Chieti, Italy
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Rodriguez EE, Zaccarelli M, Sterchele ED, Taccone FS. "NeuroVanguard": a contemporary strategy in neuromonitoring for severe adult brain injury patients. Crit Care 2024; 28:104. [PMID: 38561829 PMCID: PMC10985991 DOI: 10.1186/s13054-024-04893-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/05/2024] [Accepted: 03/27/2024] [Indexed: 04/04/2024] Open
Abstract
Severe acute brain injuries, stemming from trauma, ischemia or hemorrhage, remain a significant global healthcare concern due to their association with high morbidity and mortality rates. Accurate assessment of secondary brain injuries severity is pivotal for tailor adequate therapies in such patients. Together with neurological examination and brain imaging, monitoring of systemic secondary brain injuries is relatively straightforward and should be implemented in all patients, according to local resources. Cerebral secondary injuries involve factors like brain compliance loss, tissue hypoxia, seizures, metabolic disturbances and neuroinflammation. In this viewpoint, we have considered the combination of specific noninvasive and invasive monitoring tools to better understand the mechanisms behind the occurrence of these events and enhance treatment customization, such as intracranial pressure monitoring, brain oxygenation assessment and metabolic monitoring. These tools enable precise intervention, contributing to improved care quality for severe brain injury patients. The future entails more sophisticated technologies, necessitating knowledge, interdisciplinary collaboration and resource allocation, with a focus on patient-centered care and rigorous validation through clinical trials.
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Affiliation(s)
- Edith Elianna Rodriguez
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
| | - Mario Zaccarelli
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Elda Diletta Sterchele
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium
- School of Medicine and Health Sciences, Universidad del Rosario, Bogotá, Colombia
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
- Terapia Intensiva e del Dolore, Scuola di Anestesia Rianimazione, Università degli Studi di Milano, Milan, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Zorzi S, Ayako Minemura Ordinola A, Cunha De Souza Lima E, Martins Teixeira G, Salvagno M, Sterchele ED, Taccone FS. A glimpse into multimodal neuromonitoring in acute liver failure: a case report. Ann Med Surg (Lond) 2024; 86:539-544. [PMID: 38222739 PMCID: PMC10783349 DOI: 10.1097/ms9.0000000000001519] [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: 08/04/2023] [Accepted: 11/07/2023] [Indexed: 01/16/2024] Open
Abstract
Introduction Acute liver failure (ALF) is a rapidly progressing, life-threatening syndrome characterized by liver-related coagulopathy and hepatic encephalopathy (HE). Given that higher HE grades correlate with poorer outcomes, clinical management of ALF necessitates close neurological monitoring. The primary objective of this case report is to highlight the diagnostic value of utilizing multimodal neuromonitoring (MNM) in a patient suffering from ALF. Case report A 56-year-old male patient with a history of chronic alcoholism, without prior chronic liver disease, and recent acetaminophen use was admitted to the hospital due to fatigue and presenting with a mild flapping tremor. The primary hypothesis was an acute hepatic injury caused by acetaminophen intoxication. In the following hours, the patient's condition deteriorated, accompanied by neurological decline and rising ammonia levels. The patient's neurological status was closely monitored using MNM. Bilaterally altered pupillary light reflex assessed by decreasing in the Neurological Pupil Index values, using automated pupillometry, initially suggested severe brain oedema. However, ultrasound measurements of the optic nerve sheath diameter showed normal values in both eyes, P2/P1 noninvasive intracranial pressure waveform assessment was within normal ranges and the cerebral computed tomography-scan revealed no signs of cerebral swelling. Increased middle cerebral artery velocities measured by Transcranial Doppler and the initiation of electroencephalography monitoring yielded the presence of status epilepticus. Discussion The utilization of MNM facilitated a more comprehensive understanding of the mechanisms underlying the patient's clinical deterioration in the setting of HE. Nonetheless, future studies are needed to show feasibility and to yield valuable insights that can enhance the outcomes for patients with HE using such an approach. Given the absence of specific guidelines in this particular context, it is advisable for physicians to give further consideration to the incorporation of MNM in the management of unconscious patients with ALF.
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Affiliation(s)
- Stefano Zorzi
- Department of Intensive Care, Hôpital Universitaire de Bruxelles (HUB), Université Libre de Bruxelles (ULB), Brussels, Belgium
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Ferrete-Araujo AM, Godoy DA, Murillo-Cabezas F. Vascular injury of the supra-aortic trunks in patients with traumatic brain injury. Med Intensiva 2023:S2173-5727(23)00015-2. [PMID: 36966042 DOI: 10.1016/j.medine.2023.03.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/27/2023]
Affiliation(s)
- Ana María Ferrete-Araujo
- Unidad de Neurocríticos, Servicio de Medicina Intensiva, Hospital Universitario Virgen del Rocío, Seville, Spain; Departamento de Medicina, Facultad de Medicina, Instituto de Biomedicina de Sevilla (IBiS)/Centro de Investigaciones Científicas (CSIC)/Universidad de Sevilla, Seville, Spain.
| | - Daniel A Godoy
- Unidad de Cuidados Neurointensivos, Sanatorio Pasteur, San Fernando del Valle de Catamarca, Catamarca, Argentina; Unidad de Terapia Intensiva, Hospital San Juan Bautista, San Fernando del Valle de Catamarca, Catamarca, Argentina
| | - Francisco Murillo-Cabezas
- Departamento de Medicina, Facultad de Medicina, Instituto de Biomedicina de Sevilla (IBiS)/Centro de Investigaciones Científicas (CSIC)/Universidad de Sevilla, Seville, Spain
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9
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Lesión vascular de los troncos supraaórticos en pacientes con traumatismo craneoencefálico. Med Intensiva 2023. [DOI: 10.1016/j.medin.2023.02.009] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/06/2023]
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10
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Muacevic A, Adler JR, Soares MF, Fonseca AC. Follow-Up by Transcranial Doppler After Rupture of a Giant Intracranial Aneurysm. Cureus 2022; 14:e31951. [PMID: 36582551 PMCID: PMC9795273 DOI: 10.7759/cureus.31951] [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] [Accepted: 11/27/2022] [Indexed: 11/29/2022] Open
Abstract
Giant intracranial aneurysms (GIA) are rare and manifest primarily through subarachnoid hemorrhage (SAH), cerebral ischemia, or progressive symptoms of mass effect. Transcranial Doppler (TCD) can be used to monitor cerebral vasospasm after treatment of intracranial aneurysm allowing the adjustment of therapeutics and avoiding complications. The authors present a clinical case of a patient with a ruptured intracranial giant aneurysm in which TCD was essential to monitor vasospasm and intracranial hypertension (IH). A 53-year-old male was admitted due to a sudden headache and impaired consciousness, left hemiparesis, and dysarthria. Cerebral CT scan and CT angiography at admission showed a giant aneurysm of the right middle cerebral artery (MCA) with extensive and diffuse intraventricular SAH of Fisher grade IV and Hunt and Hess grade 4. Clipping, placement of an intracranial pressure sensor, and external ventricular drain (EVD) were performed on the same day, with difficulty in preserving the M2 branch and complicated by postoperative extensive right MCA ischemia. On day three of hospitalization, TCD revealed an increased pulsatility index (>1.5) with clinical deterioration leading to re-intervention for a decompressive craniectomy. On day six, a TCD follow-up was performed to monitor blood flow complications, and particularly vasospasm, showing a severe increase in middle blood flow velocity (MBFV) in the right MCA of 205 cm/s and Lindegaard Index > 6. Daily surveillance by TCD was maintained to guide clinical management since the attempt to withdraw the EVD led to clinical deterioration with subsequent worsening of vasospasm. Improvement occurred after surgery as ventriculoperitoneal shunt insertion was performed. TCD had a major role in the clinical orientation of SAH as well as in intracranial pressure management and was decisive to establish long-term treatment.
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Liang Y, Duan Y, Xing C, Jin J, Yan L, Liu X, Wang J. Clinical Value of TCCD for Evaluating the Prognosis of Patients with Severe Traumatic Brain Injury After Large Decompressive Craniectomy: A Retrospective Study. Adv Ther 2022; 39:4556-4567. [PMID: 35934765 DOI: 10.1007/s12325-022-02251-w] [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: 04/23/2022] [Accepted: 06/29/2022] [Indexed: 01/30/2023]
Abstract
INTRODUCTION It is challenging to assess the prognosis of patients with severe traumatic brain injury (sTBI) after large decompressive craniectomy (DC). The aim of this study was to evaluate the clinical value of transcranial color-coded duplex sonography (TCCD) for assessing the prognosis of sTBI patients 6 months after large DC. METHODS This was a retrospective observational study that consecutively enrolled 84 patients with sTBI who were followed up for prognosis until 6 months after large DC. The primary endpoint was the Glasgow Outcome Score (GOS). According to the GOS, patients were divided into an unfavorable prognosis group (GOS 1-3, n = 47) and a favorable prognosis group (GOS 4-5, n = 37). RESULTS Significant between-group differences were found in age and hemodynamic parameters (systolic peak blood flow velocity, end-diastolic blood flow velocity, mean blood flow velocity, pulsatility index and resistance index) of the middle cerebral artery detected by TCCD (P < 0.05 for all). Subsequently, ridge regression was used to build a prognostic model for patients with large DC. Based on the cerebral hemodynamic parameters measured by TCCD and age, the mean (± standard deviation) area under the curve of the prognostic model in patients with sTBI after large DC was 0.76 ± 0.22. The sensitivity and specificity were 82.08% and 74.17%, respectively. CONCLUSIONS The cerebral hemodynamic parameters detected by TCCD, combined with age, may be used to predict the outcomes of patients with sTBI at 6 months after large DC. As a noninvasive method, TCCD has the potential to assess the prognosis of these patients. TRIAL REGISTRATION ChiCTR: ChiCTR1800019758. Registered 27 November 2018-retrospectively registered ( http://www.chictr.org.cn/index.aspx ).
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Affiliation(s)
- Yuan Liang
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Yunyou Duan
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Changyang Xing
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jinglan Jin
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Lingjuan Yan
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Xi Liu
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China
| | - Jia Wang
- Department of Ultrasound Diagnosis, Tangdu Hospital, Air Force Medical University, Xi'an, China.
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12
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Valaikiene J, Schlachetzki F, Azevedo E, Kaps M, Lochner P, Katsanos AH, Walter U, Baracchini C, Bartels E, Školoudík D. Point-of-Care Ultrasound in Neurology - Report of the EAN SPN/ESNCH/ERcNsono Neuro-POCUS Working Group. ULTRASCHALL IN DER MEDIZIN (STUTTGART, GERMANY : 1980) 2022; 43:354-366. [PMID: 35512836 DOI: 10.1055/a-1816-8548] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/14/2023]
Abstract
In the last decade, ultrasound examination in neurology has been undergoing a significant expansion of its modalities. In parallel, there is an increasing demand for rapid and high-quality diagnostics in various acute diseases in the prehospital setting, the emergency room, intensive care unit, and during surgical or interventional procedures. Due to the growing need for rapid answers to clinical questions, there is particular demand for diagnostic ultrasound imaging. The Neuro-POCUS working group, a joint project by the European Academy of Neurology Scientific Panel Neurosonology, the European Society of Neurosonology and Cerebral Hemodynamics, and the European Reference Centers in Neurosonology (EAN SPN/ESNCH/ERcNsono Neuro-POCUS working group), was given the task of creating a concept for point-of-care ultrasound in neurology called "Neuro-POCUS". We introduce here a new ultrasound examination concept called point-of-care ultrasound in neurology (Neuro-POCUS) designed to streamline conclusive imaging outside of the ultrasound center, directly at the bedside. The aim of this study is to encourage neurologists to add quick and disease-oriented Neuro-POCUS to accompany the patient in the critical phase as an adjunct not a substitution for computed tomography, magnetic resonance imaging, or standard comprehensive neurosonology examination. Another goal is to avoid unwanted complications during imaging-free periods, ultimately resulting in advantages for the patient.
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Affiliation(s)
- Jurgita Valaikiene
- Center of Neurology, Clinic of Neurology and Neurosurgery, Vilnius University Faculty of Medicine, Vilnius, Lithuania
| | - Felix Schlachetzki
- Department of Neurology, Center for Vascular Neurology and Intensive Care, medbo Bezirksklinikum Regensburg, University of Regensburg, Germany
| | - Elsa Azevedo
- Department of Neurology, Centro Hospitalar Universitário de São João, Porto, Portugal
| | - Manfred Kaps
- Neurology, Justus Liebig University Giessen Faculty of Medicine, Giessen, Germany
| | - Piergiorgio Lochner
- Department of Neurology, Saarland University Hospital and Saarland University Faculty of Medicine, Homburg, Germany
| | - Aristeidis H Katsanos
- Division of Neurology, Population Health Research Institute, McMaster University, Hamilton, Canada
| | - Uwe Walter
- Department of Neurology, Rostock University Medical Center, Rostock, Germany
| | - Claudio Baracchini
- Stroke Unit and Neurosonology Laboratory, Padua University Hospital, Padova, Italy
| | - Eva Bartels
- Neurology, Center for Neurological Vascular Diagnostics, Munich, Germany
| | - David Školoudík
- Center for Health Research, University of Ostrava Faculty of Medicine, Ostrava, Czech Republic
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13
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Pan Y, Wan W, Xiang M, Guan Y. Transcranial Doppler Ultrasonography as a Diagnostic Tool for Cerebrovascular Disorders. Front Hum Neurosci 2022; 16:841809. [PMID: 35572008 PMCID: PMC9101315 DOI: 10.3389/fnhum.2022.841809] [Citation(s) in RCA: 10] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2021] [Accepted: 03/04/2022] [Indexed: 01/08/2023] Open
Abstract
Imaging techniques including transcranial Doppler (TCD), magnetic resonance imaging (MRI), computed tomography (CT), and cerebral angiography are available for cerebrovascular disease diagnosis. TCD is a less expensive, non-invasive, and practically simpler approach to diagnosing cerebrovascular disorders than the others. TCD is a commonly available and inexpensive diagnostic tool. However, owing to its large operator dependency, it has a narrow application area. Cerebrovascular disease indicates a group of disorders that alter the flow of blood in the brain. The brain’s functions can be temporarily or permanently impaired as a result of this change in blood flow. Timely diagnosis and treatment can restore the brain-impaired functions, resulting in a much-improved prognosis for the patients. This review summarizes the basic principles underlying the TCD imaging technique and its utility as a diagnostic tool for cerebrovascular disease.
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14
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Abstract
The efficacy of ultrasound (US) in real-time differential diagnosis and guiding further treatment decisions has been well demonstrated in prearrest conditions and during resuscitation. Evidence is limited regarding the application of US in postresuscitation care. Most of the patients following resuscitation remain comatose, and the requirement for transportation to other examination rooms increases their risk of injury. US can be performed at the bedside with high accessibility and timeliness without radiation. This narrative review provides an overview of current evidence regarding the application of US in identifying the cause of cardiac arrest (CA), hemodynamic monitoring, and prognostication in postresuscitation care. For identifying the cause of CA, cardiac US is mainly used to detect regional wall motion abnormality. However, postarrest myocardial dysfunction would confound the sonographic findings that a combination of electrocardiograms and biomarkers besides the cardiac US could improve the positive predictive value of coronary artery disease. For hemodynamic monitoring, left ventricular outlet tract velocity time integral has the best performance in predicting fluid responsiveness in conjunction with the passive leg raising test. The RUSH protocol assists in determining the subtypes of shock with high sensitivity and specificity in hypovolemic, cardiogenic, or obstructive shock. Evidence regarding the application of US for prognostication is still limited, and further evaluation should be needed.
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15
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Battaglini D, Premraj L, Huth S, Fanning J, Whitman G, Arora RC, Bellapart J, Bastos Porto D, Taccone FS, Suen JY, Li Bassi G, Fraser JF, Badenes R, Cho SM, Robba C. Non-Invasive Multimodal Neuromonitoring in Non-Critically Ill Hospitalized Adult Patients With COVID-19: A Systematic Review and Meta-Analysis. Front Neurol 2022; 13:814405. [PMID: 35493827 PMCID: PMC9047047 DOI: 10.3389/fneur.2022.814405] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2021] [Accepted: 03/15/2022] [Indexed: 12/26/2022] Open
Abstract
Introduction Neurological complications are frequent in patients with coronavirus disease-2019 (COVID-19). The use of non-invasive neuromonitoring in subjects without primary brain injury but with potential neurological derangement is gaining attention outside the intensive care unit (ICU). This systematic review and meta-analysis investigates the use of non-invasive multimodal neuromonitoring of the brain in non-critically ill patients with COVID-19 outside the ICU and quantifies the prevalence of abnormal neuromonitoring findings in this population. Methods A structured literature search was performed in MEDLINE/PubMed, Scopus, Cochrane, and EMBASE to investigate the use of non-invasive neuromonitoring tools, including transcranial doppler (TCD); optic nerve sheath diameter (ONSD); near-infrared spectroscopy (NIRS); pupillometry; and electroencephalography (EEG) inpatients with COVID-19 outside the ICU. The proportion of non-ICU patients with CVOID-19 and a particular neurological feature at neuromonitoring at the study time was defined as prevalence. Results A total of 6,593 records were identified through literature searching. Twenty-one studies were finally selected, comprising 368 non-ICU patients, of whom 97 were considered for the prevalence of meta-analysis. The pooled prevalence of electroencephalographic seizures, periodic and rhythmic patterns, slow background abnormalities, and abnormal background on EEG was.17 (95% CI 0.04-0.29), 0.42 (95% CI 0.01-0.82), 0.92 (95% CI 0.83-1.01), and.95 (95% CI 0.088-1.09), respectively. No studies investigating NIRS and ONSD outside the ICU were found. The pooled prevalence for abnormal neuromonitoring findings detected using the TCD and pupillometry were incomputable due to insufficient data. Conclusions Neuromonitoring tools are non-invasive, less expensive, safe, and bedside available tools with a great potential for both diagnosis and monitoring of patients with COVID-19 at risk of brain derangements. However, extensive literature searching reveals that they are rarely used outside critical care settings.Systematic Review Registration: www.crd.york.ac.uk/prospero/display_record.php?RecordID=265617, identifier: CRD42021265617.
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Affiliation(s)
- Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | | | - Samuel Huth
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Jonathon Fanning
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- St. Andrew's War Memorial Hospital, Uniting Care Health, Spring Hill, QLD, Australia
| | - Glenn Whitman
- School of Medicine, Johns Hopkins University, Baltimore, MD, United States
| | - Rakesh C. Arora
- Department of Surgery, Section of Cardiac Surgery, Max Rady College of Medicine, University of Manitoba, Winnipeg, MB, Canada
| | - Judith Bellapart
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Royal Brisbane and Women's Hospital, Brisbane, QLD, Australia
| | - Diego Bastos Porto
- Department of Critical Care, Sao Camilo Cura D'ars Hospital, Fortaleza, Brazil
| | - Fabio Silvio Taccone
- Intensive Care Unit, Erasmus Hospital, Free University of Brussels, Brussels, Belgium
| | - Jacky Y. Suen
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
| | - Gianluigi Li Bassi
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- Queensland University of Technology, Herston, QLD, Australia
- Institut de Ricerca Biomedica August Pi i Sunyer (IDIBAPS), Valencia, Spain
| | - John F. Fraser
- Critical Care Research Group (CCRG), Herston, QLD, Australia
- Faculty of Medicine, The University of Queensland, Herston, QLD, Australia
- St. Andrew's War Memorial Hospital, Uniting Care Health, Spring Hill, QLD, Australia
- Queensland University of Technology, Herston, QLD, Australia
| | - Rafael Badenes
- Department of Anesthesia and Intensive Care, Hospital Clinic Universitari, INCLIVA Research Health Institute, University of Valencia, Valencia, Spain
| | - Sung-Min Cho
- Griffith University School of Medicine, Gold Coast, QLD, Australia
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
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Kovacs M, Peluso L, Njimi H, De Witte O, Gouvêa Bogossian E, Quispe Cornejo A, Creteur J, Schuind S, Taccone FS. Optimal Cerebral Perfusion Pressure Guided by Brain Oxygen Pressure Measurement. Front Neurol 2021; 12:732830. [PMID: 34777201 PMCID: PMC8581172 DOI: 10.3389/fneur.2021.732830] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/29/2021] [Accepted: 09/29/2021] [Indexed: 11/13/2022] Open
Abstract
Background: Although increasing cerebral perfusion pressure (CPP) is commonly accepted to improve brain tissue oxygen pressure (PbtO2), it remains unclear whether recommended CPP targets (i. e., >60 mmHg) would result in adequate brain oxygenation in brain injured patients. The aim of this study was to identify the target of CPP associated with normal brain oxygenation. Methods: Prospectively collected data including patients suffering from acute brain injury and monitored with PbtO2, in whom daily CPP challenge using vasopressors was performed. Initial CPP target was >60 mmHg; norepinephrine infusion was modified to have an increase in CPP of at least 10 mmHg at two different steps above the baseline values. Whenever possible, the same CPP challenge was performed for the following days, for a maximum of 5 days. CPP “responders” were patients with a relative increase in PbtO2 from baseline values > 20%. Results: A total of 53 patients were included. On the first day of assessment, CPP was progressively increased from 73 (70–76) to 83 (80–86), and 92 (90–96) mmHg, which resulted into a significant PbtO2 increase [from 20 (17–23) mmHg to 22 (20–24) mmHg and 24 (22–26) mmHg, respectively; p < 0.001]. Median CPP value corresponding to PbtO2 values > 20 mmHg was 79 (74–87) mmHg, with 2 (4%) patients who never achieved such target. Similar results of CPP targets were observed the following days. A total of 25 (47%) were PbtO2 responders during the CPP challenge on day 1, in particular if low PbtO2 was observed at baseline. Conclusions: PbtO2 monitoring can be an effective way to individualize CPP values to avoid tissue hypoxia. Low PbtO2 values at baseline can identify the responders to the CPP challenge.
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Affiliation(s)
- Matyas Kovacs
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Hassane Njimi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Olivier De Witte
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Armin Quispe Cornejo
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Sophie Schuind
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles, Brussels, Belgium
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17
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Caldas JR, Panerai RB, Passos R, Hajjar LA. Is there still a place for transcranial Doppler in patients with IABP? CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:625. [PMID: 33097067 PMCID: PMC7585289 DOI: 10.1186/s13054-020-03324-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/15/2020] [Accepted: 10/04/2020] [Indexed: 12/02/2022]
Affiliation(s)
- Juliana R Caldas
- Critical Care Unit, Hospital São Rafael Rede DOR, Salvador, Brazil.,Universidade de Salvador- UNIFACS, Salvador, Brazil.,Escola Bahiana de Medicina e Saúde Pública- EBMSP, Salvador, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, UK.,NIHR Leicester Biomedical Research Centre, Leicester, UK
| | - Rogério Passos
- Critical Care Unit, Hospital São Rafael Rede DOR, Salvador, Brazil
| | - Ludhmila A Hajjar
- Department of Cardiopneumology, Universidade de São Paulo, São Paulo, Brazil. .,Surgical Intensive Care, Heart Institute, University of São Paulo, Av. Dr. Enéas de Carvalho Aguiar 44, São Paulo, 05403-000, Brazil.
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Tolcher MC, Fox KA, Sangi-Haghpeykar H, Clark SL, Belfort MA. Intravenous labetalol versus oral nifedipine for acute hypertension in pregnancy: effects on cerebral perfusion pressure. Am J Obstet Gynecol 2020; 223:441.e1-441.e8. [PMID: 32544404 DOI: 10.1016/j.ajog.2020.06.018] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/05/2020] [Revised: 05/25/2020] [Accepted: 06/09/2020] [Indexed: 10/24/2022]
Abstract
BACKGROUND Pregnant women with preeclampsia have been found to have elevated cerebral perfusion pressure and impaired cerebral autoregulation compared with normal pregnant women. Transcranial Doppler is a noninvasive technique used to estimate cerebral perfusion pressure. The effects of different antihypertensive medications on cerebral perfusion pressure in preeclampsia are unknown. OBJECTIVE To compare the change in cerebral perfusion pressure before and after intravenous labetalol vs oral nifedipine in the setting of acute severe hypertension in pregnancy. STUDY DESIGN This is a prospective cohort study of pregnant women between 24 and 42 weeks' gestation with severe hypertension (systolic blood pressure ≥160 mm Hg and/or diastolic blood pressure ≥110 mm Hg). Women who consented to the study and received either intravenous labetalol or oral nifedipine were included. Exclusion criteria included active labor or receipt of any antihypertensive medication within 2 hours of initial cerebral perfusion pressure measurement. Peripheral blood pressure and transcranial Doppler studies for middle cerebral artery hemodynamics were performed prior to the administration of antihypertensive medications and repeated 30 minutes after medication administration. RESULTS A total of 16 women with acute severe hypertension were enrolled; 8 received intravenous labetalol and 8 received oral nifedipine. There were no significant differences between the labetalol and nifedipine groups in baseline characteristics such as maternal age, race and ethnicity, payment, hospital site, body mass index, nulliparity, gestational age, preexisting diabetes mellitus or chronic hypertension, fetal growth restriction, magnesium sulfate administration, and symptomatology (P>.05). When examined 30 minutes after the administration of either intravenous labetalol or oral nifedipine, there was a significantly greater decrease in systolic blood pressure (-9.8 mm Hg vs -39 mm Hg; P=.003), mean arterial pressure (-7.1 mm Hg vs -22.3 mm Hg; P=.02), and cerebral perfusion pressure (-2.5 mm Hg vs -27.7 mm Hg; P=.01) in the nifedipine group. There was no statistically significant decrease in diastolic blood pressure (-12.9 mm Hg vs -5.4 mm Hg; P=.15). The change in middle cerebral artery velocity by transcranial Doppler was compared between the groups and was not different (0.07 cm/s vs 0.16 cm/s; P=.64). CONCLUSION Oral nifedipine resulted in a significant decrease in cerebral perfusion pressure, whereas labetalol did not, after administration for acute severe hypertension among women with preeclampsia. This decrease seems to be driven by a decrease in peripheral arterial blood pressure rather than a direct change in cerebral blood flow.
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Onweni CL, McLaughlin DC, Freeman WD. How I use transcranial Doppler in the ICU. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2020; 24:38. [PMID: 32020883 PMCID: PMC7001253 DOI: 10.1186/s13054-020-2750-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 01/06/2020] [Accepted: 01/26/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Chidinma L Onweni
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.,Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - Diane C McLaughlin
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA
| | - William D Freeman
- Department of Critical Care Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA. .,Department of Neurology, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA. .,Department of Neurologic Surgery, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL, 32224, USA.
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