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Kheram N, Boraschi A, Aguirre J, Farshad M, Pfender N, Curt A, Schubert M, Kurtcuoglu V, Zipser CM. Cerebrospinal fluid pressure dynamics across the intra- and postoperative setting: Retrospective study of a spine surgery cohort. J Clin Neurosci 2024; 128:110803. [PMID: 39163699 DOI: 10.1016/j.jocn.2024.110803] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/19/2024] [Revised: 08/12/2024] [Accepted: 08/13/2024] [Indexed: 08/22/2024]
Abstract
Timely and sufficient decompression are critical objectives in degenerative cervical myelopathy (DCM) and spinal cord injury (SCI). We previously investigated intraoperative cerebrospinal fluid pressure (CSFP) for determining surgical outcomes. However, confounding factors during the intra- and postoperative setting need consideration. These are related to type of respiration (i.e., artificial vs. natural) and anesthesia, which affect CSFP dynamics through the interaction between the cardiorespiratory system and the CSF compartment. This retrospective cohort study (NCT02170155) aims to systematically investigate these factors to facilitate CSFP interpretation. CSFP was continuously measured through a lumbar catheter, intra- and postoperatively, in 21 patients with DCM undergoing decompression surgery. Mean CSFP and cardiac-driven CSFP peak-to-valley amplitude (CSFPp) were analyzed throughout the perioperative period, including the immediate extubation period in eight patients. Intraoperative mean CSFP had a median value and {interquartile range} of 10.8 {5.5} mmHg and increased 1.6-fold to 16.9 {7.1} mmHg postoperatively (p < 0.001). CSFPp increased 3-fold from 0.6 {0.7} to 1.8 {2.5} mmHg (p = 0.001). Increased CSFP persisted overnight. During extubation, there was a notable increase in CSFP and CSFPp of 14.0 {5.8} and 5.1 {3.1} mmHg, respectively. From case-based analysis, this was attributed to an arterial pCO2 increase. There was no correlation between respirator settings and CSFP metrics. There were distinct and quantifiable changes in CSFP dynamics from the intra- to postoperative setting related to type of respiration, anesthesia, and level of consciousness. When monitoring CSFP dynamics in spine surgery across these settings, cardiorespiratory factors must be controlled for.
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Affiliation(s)
- Najmeh Kheram
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland; University Spine Center, Balgrist University Hospital, Zurich, Switzerland; Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - Andrea Boraschi
- Institute of Physiology, University of Zurich, Zurich, Switzerland
| | - José Aguirre
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland; Department of Anesthesiology, Balgrist University Hospital, Zurich, Switzerland
| | - Mazda Farshad
- University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Nikolai Pfender
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland; University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Armin Curt
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland; University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | - Martin Schubert
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland; University Spine Center, Balgrist University Hospital, Zurich, Switzerland
| | | | - Carl M Zipser
- Spinal Cord Injury Center, Balgrist University Hospital, Zurich, Switzerland; University Spine Center, Balgrist University Hospital, Zurich, Switzerland.
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Cardim D, Giardina A, Ciliberti P, Battaglini D, Berardino A, Uccelli A, Czosnyka M, Roccatagliata L, Matta B, Patroniti N, Rocco PRM, Robba C. Short-term mild hyperventilation on intracranial pressure, cerebral autoregulation, and oxygenation in acute brain injury patients: a prospective observational study. J Clin Monit Comput 2024; 38:753-762. [PMID: 38310592 PMCID: PMC11297838 DOI: 10.1007/s10877-023-01121-2] [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: 10/14/2023] [Accepted: 12/18/2023] [Indexed: 02/06/2024]
Abstract
Current guidelines suggest a target of partial pressure of carbon dioxide (PaCO2) of 32-35 mmHg (mild hypocapnia) as tier 2 for the management of intracranial hypertension. However, the effects of mild hyperventilation on cerebrovascular dynamics are not completely elucidated. The aim of this study is to evaluate the changes of intracranial pressure (ICP), cerebral autoregulation (measured through pressure reactivity index, PRx), and regional cerebral oxygenation (rSO2) parameters before and after induction of mild hyperventilation. Single center, observational study including patients with acute brain injury (ABI) admitted to the intensive care unit undergoing multimodal neuromonitoring and requiring titration of PaCO2 values to mild hypocapnia as tier 2 for the management of intracranial hypertension. Twenty-five patients were included in this study (40% female), median age 64.7 years (Interquartile Range, IQR = 45.9-73.2). Median Glasgow Coma Scale was 6 (IQR = 3-11). After mild hyperventilation, PaCO2 values decreased (from 42 (39-44) to 34 (32-34) mmHg, p < 0.0001), ICP and PRx significantly decreased (from 25.4 (24.1-26.4) to 17.5 (16-21.2) mmHg, p < 0.0001, and from 0.32 (0.1-0.52) to 0.12 (-0.03-0.23), p < 0.0001). rSO2 was statistically but not clinically significantly reduced (from 60% (56-64) to 59% (54-61), p < 0.0001), but the arterial component of rSO2 (ΔO2Hbi, changes in concentration of oxygenated hemoglobin of the total rSO2) decreased from 3.83 (3-6.2) μM.cm to 1.6 (0.5-3.1) μM.cm, p = 0.0001. Mild hyperventilation can reduce ICP and improve cerebral autoregulation, with minimal clinical effects on cerebral oxygenation. However, the arterial component of rSO2 was importantly reduced. Multimodal neuromonitoring is essential when titrating PaCO2 values for ICP management.
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Affiliation(s)
- Danilo Cardim
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
| | - Alberto Giardina
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genova, Italy
| | - Pietro Ciliberti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genova, Italy
| | - Denise Battaglini
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Andrea Berardino
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Antonio Uccelli
- IRCCS Ospedale Policlinico San Martino, Genova, Italy
- DINOGMI, University of Genova, Genova, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Luca Roccatagliata
- Department of Neuroradiology, IRCCS Ospedale Policlinico San Martino, Genova, Italy
- DISSAL, University of Genova, Genova, Italy
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, UK
| | - Nicolo Patroniti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genova, Italy
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
| | - Patricia R M Rocco
- Laboratory of Pulmonary Investigation, Carlos Chagas Filho Institute of Biophysics, Federal University of Rio de Janeiro, Rio de Janeiro, Brazil
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Viale Benedetto XV 16, Genova, Italy
- Department of Anesthesia and Intensive Care, IRCCS Ospedale Policlinico San Martino, Genova, Italy
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Stoisavljevic S, Stojanovic M, Zdraljevic M, Aleksic V, Pekmezovic T, Mijajlovic M. Correlation between Morphological and Hemodynamic Parameters of Carotid Arteries and Cerebral Vasomotor Reactivity. Brain Sci 2024; 14:167. [PMID: 38391741 PMCID: PMC10886859 DOI: 10.3390/brainsci14020167] [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: 01/12/2024] [Revised: 02/02/2024] [Accepted: 02/06/2024] [Indexed: 02/24/2024] Open
Abstract
The function of cerebral small vessels can be assessed using cerebral vasomotor reactivity (VMR). Our aim in this retrospective cross-sectional study was to investigate a correlation between carotid artery stenosis measured through ultrasonographic morphological and hemodynamic parameters and cerebral VMR. A total of 285 patients (125 males; mean age 54) were included. The breath-holding index (BHI) was used to evaluate cerebral VMR. Ultrasonographic carotid artery parameters were collected: the presence and characteristics of carotid plaques, the degree of carotid diameter stenosis, intima-media thickness (IMT), peak systolic velocity (PSV), and end diastolic velocity (EDV). Additionally, hemodynamic parameters of the middle cerebral artery (MCA) were evaluated, including the mean flow velocity (MFV) and pulsatility index (PI). The following was collected from patients' medical histories: age, gender, and vascular risk factors. A negative correlation between the BHI and age (r = -0.242, p < 0.01), BHI and the presence of carotid plaques, BHI and IMT (r = -0.203, p < 0.01), and BHI and the PI of MCA on both sides (r = -0.268, p < 0.01) was found. We found a positive correlation between the BHI in the left MCA and EDV in the left internal carotid artery (r = 0.121, p < 0.05). This study shows the correlation between cerebral VMR and carotid stenosis but indicates a higher influence of morphological parameters on VMR values.
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Affiliation(s)
| | - Milica Stojanovic
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Mirjana Zdraljevic
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
| | - Vuk Aleksic
- Neurosurgery Department, Clinical-Hospital Center Zemun, 11000 Belgrade, Serbia
| | | | - Milija Mijajlovic
- Faculty of Medicine, University of Belgrade, 11000 Belgrade, Serbia
- Neurology Clinic, University Clinical Center of Serbia, 11000 Belgrade, Serbia
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Szabo S, Totka Z, Nagy-Bozsoky J, Pinter I, Bagany M, Bodo M. Rheoencephalography: A non-invasive method for neuromonitoring. JOURNAL OF ELECTRICAL BIOIMPEDANCE 2024; 15:10-25. [PMID: 38482467 PMCID: PMC10936697 DOI: 10.2478/joeb-2024-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Indexed: 04/07/2024]
Abstract
In neurocritical care, the gold standard method is intracranial pressure (ICP) monitoring for the patient's lifesaving. Since it is an invasive method, it is desirable to use an alternative, noninvasive technique. The computerized real-time invasive cerebral blood flow (CBF) autoregulation (AR) monitoring calculates the status of CBF AR, called the pressure reactivity index (PRx). Studies documented that the electrical impedance of the head (Rheoencephalography - REG) can detect the status of CBF AR (REGx) and ICP noninvasively. We aimed to test REG to reflect ICP and CBF AR. For nineteen healthy subjects we recorded bipolar bifrontal and bitemporal REG derivations and arm bioimpedance pulses with a 200 Hz sampling rate. The challenges were a 30-second breath-holding and head-down-tilt (HDT - Trendelenburg) position. Data were stored and processed offline. REG pulse wave morphology and REGx were calculated. The most relevant finding was the significant morphological change of the REG pulse waveform (2nd peak increase) during the HDT position. Breath-holding caused REG amplitude increase, but it was not significant. REGx in male and female group averages have similar trends during HDT by indicating the active status of CBF AR. The morphological change of REG pulse wave during HDT position was identical to ICP waveform change during increased ICP, reflecting decreased intracranial compliance. A correlation study between ICP and REG was initiated in neurocritical care patients. The noninvasive REG monitoring would also be useful in space research as well as in military medicine during the transport of wounded service members as well as for fighter pilots to indicate the loss of CBF and consciousness.
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Affiliation(s)
- Sandor Szabo
- University of Szeged, Faculty of General Medicine, Department of Aviation and Space Medicine. Kecskemet, Hungary; Hungarian Defence Forces Medical Center, Aeromedical, Military Medical Screening and Healthcare Instituter;Kecskemet, Hungary
| | - Zsolt Totka
- University of Szeged, Faculty of General Medicine, Department of Aviation and Space Medicine. Kecskemet, Hungary; Hungarian Defence Forces Medical Center, Aeromedical, Military Medical Screening and Healthcare Instituter;Kecskemet, Hungary
| | - Jozsef Nagy-Bozsoky
- University of Szeged, Faculty of General Medicine, Department of Aviation and Space Medicine. Kecskemet, Hungary; Hungarian Defence Forces Medical Center, Aeromedical, Military Medical Screening and Healthcare Instituter;Kecskemet, Hungary
| | | | | | - Michael Bodo
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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Tsigaras ZA, Weeden M, McNamara R, Jeffcote T, Udy AA. The pressure reactivity index as a measure of cerebral autoregulation and its application in traumatic brain injury management. CRIT CARE RESUSC 2023; 25:229-236. [PMID: 38234328 PMCID: PMC10790019 DOI: 10.1016/j.ccrj.2023.10.009] [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: 10/19/2023] [Accepted: 10/30/2023] [Indexed: 01/19/2024]
Abstract
Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality globally. The Brain Trauma Foundation guidelines advocate for the maintenance of a cerebral perfusion pressure (CPP) between 60 and 70 mmHg following severe TBI. However, such a uniform goal does not account for changes in cerebral autoregulation (CA). CA refers to the complex homeostatic mechanisms by which cerebral blood flow is maintained, despite variations in mean arterial pressure and intracranial pressure. Disruption to CA has become increasingly recognised as a key mediator of secondary brain injury following severe TBI. The pressure reactivity index is calculated as the degree of statistical correlation between the slow wave components of mean arterial pressure and intracranial pressure signals and is a validated dynamic marker of CA status following brain injury. The widespread acceptance of pressure reactivity index has precipitated the consideration of individualised CPP targets or an optimal cerebral perfusion pressure (CPPopt). CPPopt represents an alternative target for cerebral haemodynamic optimisation following severe TBI, and early observational data suggest improved neurological outcomes in patients whose CPP is more proximate to CPPopt. The recent publication of a prospective randomised feasibility study of CPPopt guided therapy in TBI, suggests clinicians caring for such patients should be increasingly familiar with these concepts. In this paper, we present a narrative review of the key landmarks in the development of CPPopt and offer a summary of the evidence for CPPopt-based therapy in comparison to current standards of care.
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Affiliation(s)
| | - Mark Weeden
- St George Hospital, Kogarah, NSW 2217, Australia
| | - Robert McNamara
- Department of Intensive Care Medicine, Royal Perth Hospital, Perth, WA 6001, Australia
- School of Medicine, Curtin University, Bentley, WA 6102, Australia
| | - Toby Jeffcote
- The Alfred Hospital, Melbourne, VIC 3004, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC 3003, Australia
| | - Andrew A. Udy
- The Alfred Hospital, Melbourne, VIC 3004, Australia
- Australian and New Zealand Intensive Care Research Centre, Monash University, Melbourne, VIC 3003, Australia
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Cannizzaro LA, Iwuchukwu I, Rahaman V, Hirzallah M, Bodo M. Noninvasive neuromonitoring with rheoencephalography: a case report. J Clin Monit Comput 2023; 37:1413-1422. [PMID: 36934402 PMCID: PMC10024795 DOI: 10.1007/s10877-023-00985-8] [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: 10/06/2022] [Accepted: 02/16/2023] [Indexed: 03/20/2023]
Abstract
Cerebral blood flow (CBF) autoregulation (AR) can be monitored using invasive modalities, such as intracranial pressure (ICP) and arterial blood pressure (ABP) to calculate the CBF AR index (PRx). Monitoring PRx can reduce the extent of secondary brain damage in patients. Rheoencephalography (REG) is an FDA-approved non-invasive method to measure CBF. REGx, a CBF AR index, is calculated from REG and arm bioimpedance pulse waves. Our goal was to test REG for neuromonitoring. 28 measurement sessions were performed on 13 neurocritical care patients. REG/arm bioimpedance waveforms were recorded on a laptop using a bioimpedance amplifier and custom-built software. The same program was used for offline data processing. Case #1: The patient's mean REGx increased from - 0.08 on the first day to 0.44 on the second day, indicating worsening intracranial compliance (ICC) (P < 0.0001, CI 0.46-0.58). Glasgow Coma Scale (GCS) was 5 on both days. Case #2: REGx decreased from 0.32 on the first recording to 0.07 on the last (P = 0.0003, CI - 0.38 to - 0.12). GCS was 7 and 14, respectively. Case #3: Within a 36-minute recording, REGx decreased from 0.56 to - 0.37 (P < 0.0001, 95%, CI - 1.10 to - 0.76). Central venous pressure changed from 14 to 9 mmHg. REG pulse wave morphology changed from poor ICC to good ICC morphology. Bioimpedance recording made it possible to quantify the active/passive status of CBF AR, indicate the worsening of ICC, and present it in real time. REGx can be a suitable, non-invasive alternative to PRx for use in head-injured patients.
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Affiliation(s)
| | | | | | | | - Michael Bodo
- 1Ochsner Medical Center, New Orleans, LA, USA.
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA.
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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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Chandrasekhar A, Padrós-Valls R, Pallarès-López R, Palanques-Tost E, Houstis N, Sundt TM, Lee HS, Sodini CG, Aguirre AD. Tissue perfusion pressure enables continuous hemodynamic evaluation and risk prediction in the intensive care unit. Nat Med 2023; 29:1998-2006. [PMID: 37550417 DOI: 10.1038/s41591-023-02474-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/03/2023] [Accepted: 06/27/2023] [Indexed: 08/09/2023]
Abstract
Treatment of circulatory shock in critically ill patients requires management of blood pressure using invasive monitoring, but uncertainty remains as to optimal individual blood pressure targets. Critical closing pressure, which refers to the arterial pressure when blood flow stops, can provide a fundamental measure of vascular tone in response to disease and therapy, but it has not previously been possible to measure this parameter routinely in clinical care. Here we describe a method to continuously measure critical closing pressure in the systemic circulation using readily available blood pressure monitors and then show that tissue perfusion pressure (TPP), defined as the difference between mean arterial pressure and critical closing pressure, provides unique information compared to other hemodynamic parameters. Using analyses of 5,988 admissions to a modern cardiac intensive care unit, and externally validated with 864 admissions to another institution, we show that TPP can predict the risk of mortality, length of hospital stay and peak blood lactate levels. These results indicate that TPP may provide an additional target for blood pressure optimization in patients with circulatory shock.
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Affiliation(s)
- Anand Chandrasekhar
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Raimon Padrós-Valls
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Roger Pallarès-López
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Eric Palanques-Tost
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA
| | - Nicholas Houstis
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA
| | - Thoralf M Sundt
- Cardiac Surgery Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Hae-Seung Lee
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Charles G Sodini
- Department of Electrical Engineering and Computer Science, Massachusetts Institute of Technology, Cambridge, MA, USA
- Institute for Medical Engineering and Science, Massachusetts Institute of Technology, Cambridge, MA, USA
| | - Aaron D Aguirre
- Cardiology Division, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
- Wellman Center for Photomedicine, Massachusetts General Hospital, Boston, MA, USA.
- Healthcare Transformation Lab, Massachusetts General Hospital, Boston, MA, USA.
- Center for Systems Biology, Massachusetts General Hospital, Boston, MA, USA.
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Kastenholz N, Megjhani M, Conzen-Dilger C, Albanna W, Veldeman M, Nametz D, Kwon SB, Schulze-Steinen H, Ridwan H, Clusmann H, Schubert GA, Park S, Weiss M. The oxygen reactivity index indicates disturbed local perfusion regulation after aneurysmal subarachnoid hemorrhage: an observational cohort study. Crit Care 2023; 27:235. [PMID: 37312192 PMCID: PMC10265851 DOI: 10.1186/s13054-023-04452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/19/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Cerebral autoregulation (CA) can be impaired in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The Pressure Reactivity Index (PRx, correlation of blood pressure and intracranial pressure) and Oxygen Reactivity Index (ORx, correlation of cerebral perfusion pressure and brain tissue oxygenation, PbtO2) are both believed to estimate CA. We hypothesized that CA could be poorer in hypoperfused territories during DCI and that ORx and PRx may not be equally effective in detecting such local variances. METHODS ORx and PRx were compared daily in 76 patients with aSAH with or without DCI until the time of DCI diagnosis. The ICP/PbtO2-probes of DCI patients were retrospectively stratified by being in or outside areas of hypoperfusion via CT perfusion image, resulting in three groups: DCI + /probe + (DCI patients, probe located inside the hypoperfused area), DCI + /probe- (probe outside the hypoperfused area), DCI- (no DCI). RESULTS PRx and ORx were not correlated (r = - 0.01, p = 0.56). Mean ORx but not PRx was highest when the probe was located in a hypoperfused area (ORx DCI + /probe + 0.28 ± 0.13 vs. DCI + /probe- 0.18 ± 0.15, p < 0.05; PRx DCI + /probe + 0.12 ± 0.17 vs. DCI + /probe- 0.06 ± 0.20, p = 0.35). PRx detected poorer autoregulation during the early phase with relatively higher ICP (days 1-3 after hemorrhage) but did not differentiate the three groups on the following days when ICP was lower on average. ORx was higher in the DCI + /probe + group than in the other two groups from day 3 onward. ORx and PRx did not differ between patients with DCI, whose probe was located elsewhere, and patients without DCI (ORx DCI + /probe- 0.18 ± 0.15 vs. DCI- 0.20 ± 0.14; p = 0.50; PRx DCI + /probe- 0.06 ± 0.20 vs. DCI- 0.08 ± 0.17, p = 0.35). CONCLUSIONS PRx and ORx are not interchangeable measures of autoregulation, as they likely measure different homeostatic mechanisms. PRx represents the classical cerebrovascular reactivity and might be better suited to detect disturbed autoregulation during phases with moderately elevated ICP. Autoregulation may be poorer in territories affected by DCI. These local perfusion disturbances leading up to DCI may be more readily detected by ORx than PRx. Further research should investigate their robustness to detect DCI and to serve as a basis for autoregulation-targeted treatment after aSAH.
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Affiliation(s)
- Nick Kastenholz
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Murad Megjhani
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Daniel Nametz
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Soon Bin Kwon
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Henna Schulze-Steinen
- Department of Intensive Care Medicine and Perioperative Care, RWTH Aachen University, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Soojin Park
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
- Department of Biomedical Informatics, Columbia University, New York City, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
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10
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Hassett CE, Uysal SP, Butler R, Moore NZ, Cardim D, Gomes JA. Assessment of Cerebral Autoregulation Using Invasive and Noninvasive Methods of Intracranial Pressure Monitoring. Neurocrit Care 2023; 38:591-599. [PMID: 36050535 DOI: 10.1007/s12028-022-01585-1] [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: 05/28/2022] [Accepted: 08/05/2022] [Indexed: 10/14/2022]
Abstract
BACKGROUND Pulse amplitude index (PAx), a descriptor of cerebrovascular reactivity, correlates the changes of the pulse amplitude of the intracranial pressure (ICP) waveform (AMP) with changes in mean arterial pressure (MAP). AMP relies on cerebrovascular compliance, which is modulated by the state of the cerebrovascular reactivity. PAx can aid in prognostication after acute brain injuries as a tool for the assessment of cerebral autoregulation and could potentially tailor individual management; however, invasive measurements are required for its calculation. Our aim was to evaluate the relationship between noninvasive PAx (nPAx) derived from a novel noninvasive device for ICP monitoring and PAx derived from gold standard invasive methods. METHODS We retrospectively analyzed invasive ICP (external ventricular drain) and non-invasive ICP (nICP), via mechanical extensometer (Brain4Care Corp.). Invasive and non-invasive ICP waveform morphology data was collected in adult patients with brain injury with arterial blood pressure monitoring. The time series from all signals were first treated to remove movement artifacts. PAx and nPAx were calculated as the moving correlation coefficients of 10-s averages of AMP or non-invasive AMP (nAMP) and MAP. AMP/nAMP was determined by calculating the fundamental frequency amplitude of the ICP/nICP signal over a 10-s window, updated every 10-s. We then evaluated the relationship between invasive PAx and noninvasive nPAx using the methods of repeated-measures analysis to generate an estimate of the correlation coefficient and its 95% confidence interval (CI). The agreement between the two methods was assessed using the Bland-Altman test. RESULTS Twenty-four patients were identified. The median age was 53.5 years (interquartile range 40-70), and intracranial hemorrhage (84%) was the most common etiology. Twenty-one (87.5%) patients underwent mechanical ventilation, and 60% were sedated with a median Glasgow Coma Scale score of 8 (7-15). Mean PAx was 0.0296 ± 0.331, and nPAx was 0.0171 ± 0.332. The correlation between PAx and nPAx was strong (R = 0.70, p < 0.0005, 95% CI 0.687-0.717). Bland-Altman analysis showed excellent agreement, with a bias of - 0.018 (95% CI - 0.026 to - 0.01) and a localized regression trend line that did not deviate from 0. CONCLUSIONS PAx can be calculated by conventional and noninvasive ICP monitoring in a statistically significant evaluation with strong agreement. Further study of the applications of this clinical tool is warranted, with the goal of early therapeutic intervention to improve neurologic outcomes following acute brain injuries.
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Affiliation(s)
- Catherine E Hassett
- Cerebrovascular Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44102, USA.
| | - S Pinar Uysal
- Department of Neurology, Cleveland Clinic Foundation, Cleveland, OH, USA
| | - Robert Butler
- Department of Quantitative Health Sciences, Cleveland Clinic, Cleveland, OH, USA
| | - Nina Z Moore
- Cerebrovascular Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44102, USA
- Department of Neurosurgery, Cleveland Clinic, Cleveland, OH, USA
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, USA
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, USA
| | - Joao A Gomes
- Cerebrovascular Center, Neurologic Institute, Cleveland Clinic, 9500 Euclid Avenue, Cleveland, OH, 44102, USA
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11
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Giardina A, Cardim D, Ciliberti P, Battaglini D, Ball L, Kasprowicz M, Beqiri E, Smielewski P, Czosnyka M, Frisvold S, Groznik M, Pelosi P, Robba C. Effects of positive end-expiratory pressure on cerebral hemodynamics in acute brain injury patients. Front Physiol 2023; 14:1139658. [PMID: 37200838 PMCID: PMC10185889 DOI: 10.3389/fphys.2023.1139658] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2023] [Accepted: 04/14/2023] [Indexed: 05/20/2023] Open
Abstract
Background: Cerebral autoregulation is the mechanism that allows to maintain the stability of cerebral blood flow despite changes in cerebral perfusion pressure. Maneuvers which increase intrathoracic pressure, such as the application of positive end-expiratory pressure (PEEP), have been always challenged in brain injured patients for the risk of increasing intracranial pressure (ICP) and altering autoregulation. The primary aim of this study is to assess the effect of PEEP increase (from 5 to 15 cmH2O) on cerebral autoregulation. Secondary aims include the effect of PEEP increase on ICP and cerebral oxygenation. Material and Methods: Prospective, observational study including adult mechanically ventilated patients with acute brain injury requiring invasive ICP monitoring and undergoing multimodal neuromonitoring including ICP, cerebral perfusion pressure (CPP) and cerebral oxygenation parameters obtained with near-infrared spectroscopy (NIRS), and an index which expresses cerebral autoregulation (PRx). Additionally, values of arterial blood gases were analyzed at PEEP of 5 and 15 cmH2O. Results are expressed as median (interquartile range). Results: Twenty-five patients were included in this study. The median age was 65 years (46-73). PEEP increase from 5 to 15 cmH2O did not lead to worsened autoregulation (PRx, from 0.17 (-0.003-0.28) to 0.18 (0.01-0.24), p = 0.83). Although ICP and CPP changed significantly (ICP: 11.11 (6.73-15.63) to 13.43 (6.8-16.87) mm Hg, p = 0.003, and CPP: 72.94 (59.19-84) to 66.22 (58.91-78.41) mm Hg, p = 0.004), these parameters did not reach clinically relevant levels. No significant changes in relevant cerebral oxygenation parameters were observed. Conclusion: Slow and gradual increases of PEEP did not alter cerebral autoregulation, ICP, CPP and cerebral oxygenation to levels triggering clinical interventions in acute brain injury patients.
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Affiliation(s)
- Alberto Giardina
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States
- Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Pietro Ciliberti
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
| | | | - Lorenzo Ball
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Shirin Frisvold
- Anesthesia and Intensive Care, University Hospital of Northern Norway, Tromsø, Norway
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
| | - Chiara Robba
- Dipartimento di Scienze Chirurgiche e Diagnostiche, University of Genoa, Genova, Italy
- IRCCS Policlinico San Martino, Genova, Italy
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12
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dos Santos KRM, Katsidoniotaki MI, Miller EC, Petersen NH, Marshall RS, Kougioumtzoglou IA. Reduced-order modeling and analysis of dynamic cerebral autoregulation via diffusion maps. Physiol Meas 2023; 44:10.1088/1361-6579/acc780. [PMID: 36963111 PMCID: PMC11271258 DOI: 10.1088/1361-6579/acc780] [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: 12/19/2022] [Accepted: 03/24/2023] [Indexed: 03/26/2023]
Abstract
Objective.A data-driven technique for parsimonious modeling and analysis of dynamic cerebral autoregulation (DCA) is developed based on the concept of diffusion maps. Specifically, first, a state-space description of DCA dynamics is considered based on arterial blood pressure, cerebral blood flow velocity, and their time derivatives. Next, an eigenvalue analysis of the Markov matrix of a random walk on a graph over the dataset domain yields a low-dimensional representation of the intrinsic dynamics. Further dimension reduction is made possible by accounting only for the two most significant eigenvalues. The value of their ratio indicates whether the underlying system is governed by active or hypoactive dynamics, indicating healthy or impaired DCA function, respectively. We assessed the reliability of the technique by considering healthy individuals and patients with unilateral internal carotid artery (ICA) stenosis or occlusion. We computed the sensitivity of the technique to detect the presumed side-to-side difference in the DCA function of the second group (assuming hypoactive dynamics on the occluded or stenotic side), using McNemar's chi square test. The results were compared with transfer function analysis (TFA). The performance of the two methods was also compared under the assumption of missing data.Main results.Both diffusion maps and TFA suggested a physiological side-to-side difference in the DCA of ICA stenosis or occlusion patients with a sensitivity of 81% and 71%, respectively. Further, both two methods suggested the difference between the occluded or stenotic side and any two sides of the healthy group. However, the diffusion maps captured additional difference between the unoccluded side and the healthy group, that TFA did not. Furthermore, compared to TFA, diffusion maps exhibited superior performance when subject to missing data.Significance.The eigenvalues ratio derived using the diffusion maps technique can be potentially used as a reliable and robust biomarker for assessing how active the intrinsic dynamics of the autoregulation is and for indicating healthy versus impaired DCA function.
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Affiliation(s)
- K R M dos Santos
- Department of Civil, Environmental, and Geo- Engineering, University of Minnesota, Minneapolis, MN, United States of America
| | - M I Katsidoniotaki
- Department of Civil Engineering and Engineering Mechanics, Columbia University, New York, NY, United States of America
| | - E C Miller
- Neurology-Stroke Division, Neurological Institute of New York, Columbia University Medical Center, New York, NY, United States of America
| | - N H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, CT, United States of America
| | - R S Marshall
- Neurology-Stroke Division, Neurological Institute of New York, Columbia University Medical Center, New York, NY, United States of America
| | - I A Kougioumtzoglou
- Department of Civil Engineering and Engineering Mechanics, Columbia University, New York, NY, United States of America
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13
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Ciliberti P, Cardim D, Giardina A, Groznik M, Ball L, Giovannini M, Battaglini D, Beqiri E, Matta B, Smielewski P, Czosnyka M, Pelosi P, Robba C. Effects of short-term hyperoxemia on cerebral autoregulation and tissue oxygenation in acute brain injured patients. Front Physiol 2023; 14:1113386. [PMID: 36846344 PMCID: PMC9944047 DOI: 10.3389/fphys.2023.1113386] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/25/2023] [Indexed: 02/10/2023] Open
Abstract
Introduction: Potential detrimental effects of hyperoxemia on outcomes have been reported in critically ill patients. Little evidence exists on the effects of hyperoxygenation and hyperoxemia on cerebral physiology. The primary aim of this study is to assess the effect of hyperoxygenation and hyperoxemia on cerebral autoregulation in acute brain injured patients. We further evaluated potential links between hyperoxemia, cerebral oxygenation and intracranial pressure (ICP). Methods: This is a single center, observational, prospective study. Acute brain injured patients [traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracranial hemorrhage (ICH)] undergoing multimodal brain monitoring through a software platform (ICM+) were included. Multimodal monitoring consisted of invasive ICP, arterial blood pressure (ABP) and near infrared spectrometry (NIRS). Derived parameters of ICP and ABP monitoring included the pressure reactivity index (PRx) to assess cerebral autoregulation. ICP, PRx, and NIRS-derived parameters (cerebral regional saturation of oxygen, changes in concentration of regional oxy- and deoxy-hemoglobin), were evaluated at baseline and after 10 min of hyperoxygenation with a fraction of inspired oxygen (FiO2) of 100% using repeated measures t-test or paired Wilcoxon signed-rank test. Continuous variables are reported as median (interquartile range). Results: Twenty-five patients were included. The median age was 64.7 years (45.9-73.2), and 60% were male. Thirteen patients (52%) were admitted for TBI, 7 (28%) for SAH, and 5 (20%) patients for ICH. The median value of systemic oxygenation (partial pressure of oxygen-PaO2) significantly increased after FiO2 test, from 97 (90-101) mm Hg to 197 (189-202) mm Hg, p < 0.0001. After FiO2 test, no changes were observed in PRx values (from 0.21 (0.10-0.43) to 0.22 (0.15-0.36), p = 0.68), nor in ICP values (from 13.42 (9.12-17.34) mm Hg to 13.34 (8.85-17.56) mm Hg, p = 0.90). All NIRS-derived parameters reacted positively to hyperoxygenation as expected. Changes in systemic oxygenation and the arterial component of cerebral oxygenation were significantly correlated (respectively ΔPaO2 and ΔO2Hbi; r = 0.49 (95% CI = 0.17-0.80). Conclusion: Short-term hyperoxygenation does not seem to critically affect cerebral autoregulation.
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Affiliation(s)
- Pietro Ciliberti
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Danilo Cardim
- Department of Neurology, University of Texas Southwestern Medical Center, Dallas, TX, United States,Institute for Exercise and Environmental Medicine, Texas Health Presbyterian Hospital, Dallas, TX, United States
| | - Alberto Giardina
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Matjaž Groznik
- Traumatology Department of the University Clinical Center Ljubljana, Ljubljana, Slovenia
| | - Lorenzo Ball
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Martina Giovannini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Denise Battaglini
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Basil Matta
- Neurocritical Care Unit, Addenbrooke’s Hospital, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy,Anesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy,*Correspondence: Chiara Robba,
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14
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Brain Bioenergetics in Chronic Hypertension: Risk Factor for Acute Ischemic Stroke. Biochem Pharmacol 2022; 205:115260. [PMID: 36179931 DOI: 10.1016/j.bcp.2022.115260] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/30/2022] [Revised: 09/13/2022] [Accepted: 09/14/2022] [Indexed: 11/23/2022]
Abstract
Chronic hypertension is one of the key modifiable risk factors for acute ischemic stroke, also contributing to determine greater neurological deficits and worse functional outcome when an acute cerebrovascular event would occur. A tight relationship exists between cerebrovascular autoregulation, neuronal activity and brain bioenergetics. In chronic hypertension, progressive adaptations of these processes occur as an attempt to cope with the demanding necessity of brain functions, creating a new steady-state homeostatic condition. However, these adaptive modifications are insufficient to grant an adequate response to possible pathological perturbations of the established fragile hemodynamic and metabolic homeostasis. In this narrative review, we will discuss the main mechanisms by which alterations in brain bioenergetics and mitochondrial function in chronic hypertension could lead to increased risk of acute ischemic stroke, stressing the interconnections between hemodynamic factors (i.e. cerebral autoregulation and neurovascular coupling) and metabolic processes. Both experimental and clinical pieces of evidence will be discussed. Moreover, the potential role of mitochondrial dysfunction in determining, or at least sustaining, the pathogenesis and progression of chronic neurogenic hypertension will be considered. In the perspective of novel therapeutic strategies aiming at improving brain bioenergetics, we propose some determinant factors to consider in future studies focused on the cause-effect relationships between chronic hypertension and brain bioenergetic abnormalities (and vice versa), so to help translational research in this so-far unfilled gap.
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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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16
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Longhitano Y, Iannuzzi F, Bonatti G, Zanza C, Messina A, Godoy D, Dabrowski W, Xiuyun L, Czosnyka M, Pelosi P, Badenes R, Robba C. Cerebral Autoregulation in Non-Brain Injured Patients: A Systematic Review. Front Neurol 2021; 12:732176. [PMID: 34899560 PMCID: PMC8660115 DOI: 10.3389/fneur.2021.732176] [Citation(s) in RCA: 10] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/28/2021] [Accepted: 10/11/2021] [Indexed: 01/12/2023] Open
Abstract
Introduction: Cerebral autoregulation (CA) plays a fundamental role in the maintenance of adequate cerebral blood flow (CBF). CA monitoring, through direct and indirect techniques, may guide an appropriate therapeutic approach aimed at improving CBF and reducing neurological complications; so far, the role of CA has been investigated mainly in brain-injured patients. The aim of this study is to investigate the role of CA in non-brain injured patients. Methods: A systematic consultation of literature was carried out. Search terms included: “CA and sepsis,” “CA and surgery,” and “CA and non-brain injury.” Results: Our research individualized 294 studies and after screening, 22 studies were analyzed in this study. Studies were divided in three groups: CA in sepsis and septic shock, CA during surgery, and CA in the pediatric population. Studies in sepsis and intraoperative setting highlighted a relationship between the incidence of sepsis-associated delirium and impaired CA. The most investigated setting in the pediatric population is cardiac surgery, but the role and measurement of CA need to be further elucidated. Conclusion: In non-brain injured patients, impaired CA may result in cognitive dysfunction, neurological damage, worst outcome, and increased mortality. Monitoring CA might be a useful tool for the bedside optimization and individualization of the clinical management in this group of patients.
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Affiliation(s)
- Yaroslava Longhitano
- Department of Anesthesiology and Critical Care, AO St. Antonio, Biagio and Cesare Arrigo, Alessandria, Italy
| | - Francesca Iannuzzi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Giulia Bonatti
- Anesthesia and Intensive Care, Gaslini Hospital, Genova, Italy
| | - Christian Zanza
- Foundation of "Nuovo Ospedale Alba-Bra" and Department of Emergency Medicine, Anesthesia and Critical Care Division, Michele and Pietro Ferrero Hospital, Verduno, Italy
| | - Antonio Messina
- Humanitas Clinical and Research Center - IRCCS, Milan, Italy.,Department of Biomedical Sciences, Humanitas University, Milan, Italy
| | - Daniel Godoy
- Neurointensive Care Unit, Sanatorio Pasteur, 2 Intensive Care Unit, Hospital Carlos Malbran, Catamarca, Argentina
| | | | - Li Xiuyun
- Department of Anesthesiology & Critical Care Medicine, John Hopkins University, Baltimore, MD, United States
| | - 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.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Rafael Badenes
- Department of Anesthesiology and Surgical-Trauma Intensive Care, Hospital Clinic Universitari de Valencia, Department of Surgery, University of Valencia, Valencia, Spain
| | - Chiara Robba
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy.,Anesthesia and Critical Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
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17
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Basic ultrasound head-to-toe skills for intensivists in the general and neuro intensive care unit population: consensus and expert recommendations of the European Society of Intensive Care Medicine. Intensive Care Med 2021; 47:1347-1367. [PMID: 34787687 PMCID: PMC8596353 DOI: 10.1007/s00134-021-06486-z] [Citation(s) in RCA: 75] [Impact Index Per Article: 25.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/11/2021] [Accepted: 07/16/2021] [Indexed: 01/21/2023]
Abstract
Purpose To provide consensus, and a list of experts’ recommendations regarding the basic skills for head-to-toe ultrasonography in the intensive care setting. Methods The Executive Committee of the European Society of Intensive Care (ESICM) commissioned the project and supervised the methodology and structure of the consensus. We selected an international panel of 19 expert clinicians–researchers in intensive care unit (ICU) with expertise in critical care ultrasonography (US), plus a non-voting methodologist. The panel was divided into five subgroups (brain, lung, heart, abdomen and vascular ultrasound) which identified the domains and generated a list of questions to be addressed by the panel. A Delphi process based on an iterative approach was used to obtain the final consensus statements. Statements were classified as a strong recommendation (84% of agreement), weak recommendation (74% of agreement), and no recommendation (less than 74%), in favor or against. Results This consensus produced a total of 74 statements (7 for brain, 20 for lung, 20 for heart, 20 for abdomen, 7 for vascular Ultrasound). We obtained strong agreement in favor for 49 statements (66.2%), 8 weak in favor (10.8%), 3 weak against (4.1%), and no consensus in 14 cases (19.9%). In most cases when consensus was not obtained, it was felt that the skills were considered as too advanced. A research agenda and discussion on training programs were implemented from the results of the consensus. Conclusions This consensus provides guidance for the basic use of critical care US and paves the way for the development of training and research projects. Supplementary Information The online version contains supplementary material available at 10.1007/s00134-021-06486-z.
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18
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Tas J, Beqiri E, van Kaam RC, Czosnyka M, Donnelly J, Haeren RH, van der Horst ICC, Hutchinson PJ, van Kuijk SMJ, Liberti AL, Menon DK, Hoedemaekers CWE, Depreitere B, Smielewski P, Meyfroidt G, Ercole A, Aries MJH. Targeting Autoregulation-Guided Cerebral Perfusion Pressure after Traumatic Brain Injury (COGiTATE): A Feasibility Randomized Controlled Clinical Trial. J Neurotrauma 2021; 38:2790-2800. [PMID: 34407385 DOI: 10.1089/neu.2021.0197] [Citation(s) in RCA: 97] [Impact Index Per Article: 32.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Managing traumatic brain injury (TBI) patients with a cerebral perfusion pressure (CPP) near to the cerebral autoregulation (CA)-guided "optimal" CPP (CPPopt) value is associated with improved outcome and might be useful to individualize care, but has never been prospectively evaluated. This study evaluated the feasibility and safety of CA-guided CPP management in TBI patients requiring intracranial pressure monitoring and therapy (TBIicp patients). The CPPopt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) parallel two-arm feasibility trial took place in four tertiary centers. TBIicp patients were randomized to either the Brain Trauma Foundation (BTF) guideline CPP target range (control group) or to the individualized CA-guided CPP targets (intervention group). CPP targets were guided by six times daily software-based alerts for up to 5 days. The primary feasibility end-point was the percentage of time with CPP concordant (±5 mm Hg) with the set CPP targets. The main secondary safety end-point was an increase in therapeutic intensity level (TIL) between the control and intervention group. Twenty-eight patients were randomized to the control and 32 patients to the intervention group. CPP in the intervention group was in the target range for 46.5% (interquartile range, 41.2-58) of the monitored time, significantly higher than the feasibility target specified in the published protocol (36%; p < 0.001). There were no significant differences between groups for TIL or for other safety end-points. Conclusively, targeting an individual and dynamic CA-guided CPP is feasible and safe in TBIicp patients. This encourages a prospective trial powered for clinical outcomes.
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Ruud C van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Roel H Haeren
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Neurosurgery, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Iwan C C van der Horst
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Cardiovascular Research Institute Maastricht (CARIM), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Sander M J van Kuijk
- Department of Clinical Epidemiology and Medical Technology Assessment, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Analisa L Liberti
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Anaesthesia and Intensive Care, San Carlo Borromeo Hospital, Milan, Italy
| | - David K Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | | | - Bart Depreitere
- Neurosurgery, University Hospitals Leuven, KU Leuven, Leuven, Belgium
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, KU Leuven, Leuven, Belgium
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Marcel J H Aries
- Department of Intensive Care Medicine, University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), University Maastricht (KEMTA), Maastricht University Medical Center+, Maastricht, The Netherlands
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19
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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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Tsaousi G, Tramontana A, Yamani F, Bilotta F. Cerebral Perfusion and Brain Oxygen Saturation Monitoring with: Jugular Venous Oxygen Saturation, Cerebral Oximetry, and Transcranial Doppler Ultrasonography. Anesthesiol Clin 2021; 39:507-523. [PMID: 34392882 DOI: 10.1016/j.anclin.2021.03.009] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
Accumulating evidence indicates that cerebral desaturation in the perioperative period occurs more frequently than recognized. Combining monitoring modalities that reflect different aspects of cerebral perfusion status, such as near-infrared spectroscopy, jugular bulb saturation, and transcranial Doppler ultrasonography, may provide an extended window for prevention, early detection, and prompt intervention in ongoing hypoxic/ischemic neuronal injury and, thereby, improve neurologic outcome. Such an approach would minimize the impact of limitations of each monitoring modality, while individual components complement each other, enhancing the accuracy of acquired information. Current literature has failed to demonstrate any clear-cut clinical benefit of these modalities on outcome prognosis.
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Affiliation(s)
- Georgia Tsaousi
- Department of Anesthesiology and ICU, School of Medicine, Faculty of Health Sciences, Aristotle University of Thessaloniki, University Campus, 54124 Thessaloniki, Greece
| | - Alessio Tramontana
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy
| | - Farouk Yamani
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy
| | - Federico Bilotta
- Department of Anesthesiology, Critical Care and Pain Medicine, Policlinico Umberto I, "Sapienza" University of Rome, viale del Policlinico 151, 00185 Rome, Italy.
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21
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Fedriga M, Czigler A, Nasr N, Zeiler FA, Park S, Donnelly J, Papaioannou V, Frisvold SK, Wolf S, Rasulo F, Sykora M, Smielewski P, Czosnyka M. Autonomic Nervous System Activity during Refractory Rise in Intracranial Pressure. J Neurotrauma 2021; 38:1662-1669. [PMID: 33280491 PMCID: PMC8336253 DOI: 10.1089/neu.2020.7091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Refractory intracranial hypertension (RIH) is a dramatic increase in intracranial pressure (ICP) that cannot be controlled by treatment. Recent reports suggest that the autonomic nervous system (ANS) activity may be altered during changes in ICP. Our study aimed to assess ANS activity during RIH and the causal relationship between rising in ICP and autonomic activity. We reviewed retrospectively 24 multicenter (Cambridge, Tromso, Berlin) patients in whom RIH developed as a pre-terminal event after acute brain injury (ABI). They were monitored with ICP, arterial blood pressure (ABP), and electrocardiography (ECG) using ICM+ software. Parameters reflecting autonomic activity were computed in time and frequency domain through the measurement of heart rate variability (HRV) and baroreflex sensitivity (BRS). Our results demonstrated that a rise in ICP was associated to a significant rise in HRV and BRS with a higher significance level in the high-frequency HRV (p < 0.001). This increase was followed by a significant decrease in HRV and BRS above the upper-breakpoint of ICP where ICP pulse-amplitude starts to decrease whereas the mean ICP continues to rise. Temporality measured with a Granger test suggests a causal relationship from ICP to ANS. The above results suggest that a rise in ICP interacts with ANS activity, mainly interfacing with the parasympathetic-system. The ANS seems to react to the rise in ICP with a response possibly focused on maintaining the cerebrovascular homeostasis. This happens until the critical threshold of ICP is reached above which the ANS variables collapse, probably because of low perfusion of the brain and the central autonomic network.
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Affiliation(s)
- Marta Fedriga
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Andras Czigler
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs, Pecs, Hungary
| | - Nathalie Nasr
- Unitè de Neurologie Vasculaire, CHU de Toulouse, Universitè de Toulouse, Toulouse, France
| | - Frederick. A. Zeiler
- Department of Surgery, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Soojin Park
- Department of Neurology, Division of Hospitalist and Critical Care Neurology, Columbia University, New York, New York, USA
| | - Joseph Donnelly
- Department of Anaesthesiology, University of Auckland, Aukland, New Zealand
| | - Vasilios Papaioannou
- University Hospital of Alexandroupolis, Intensive Care Unit, Democritus University of Thrace, Alexandroupolis, Greece
| | - Shirin K Frisvold
- Department of Intensive Care, University Hospital of North Norway, UiT The Arctic University of Norway, Tromso, Norway
| | - Stephan Wolf
- Department of Neurosurgery, Charite Hospital, Berlin, Germany
| | - Frank Rasulo
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Marek Sykora
- Department of Neurology, St. John's Hospital Vienna, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Smielewski
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
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22
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Tas J, Beqiri E, van Kaam CR, Ercole A, Bellen G, Bruyninckx D, Cabeleira M, Czosnyka M, Depreitere B, Donnelly J, Fedriga M, Hutchinson PJ, Menon D, Meyfroidt G, Liberti A, Outtrim JG, Robba C, Hoedemaekers CWE, Smielewski P, Aries MJ. An Update on the COGiTATE Phase II Study: Feasibility and Safety of Targeting an Optimal Cerebral Perfusion Pressure as a Patient-Tailored Therapy in Severe Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:143-147. [PMID: 33839835 DOI: 10.1007/978-3-030-59436-7_29] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Monitoring of cerebral autoregulation (CA) in patients with a traumatic brain injury (TBI) can provide an individual 'optimal' cerebral perfusion pressure (CPP) target (CPPopt) at which CA is best preserved. This potentially offers an individualized precision medicine approach. Retrospective data suggest that deviation of CPP from CPPopt is associated with poor outcomes. We are prospectively assessing the feasibility and safety of this approach in the COGiTATE [CPPopt Guided Therapy: Assessment of Target Effectiveness] study. Its primary objective is to demonstrate the feasibility of individualizing CPP at CPPopt in TBI patients. The secondary objectives are to investigate the safety and physiological effects of this strategy. METHODS The COGiTATE study has included patients in four European hospitals in Cambridge, Leuven, Nijmegen, and Maastricht (coordinating centre). Patients with severe TBI requiring intracranial pressure (ICP)-directed therapy are allocated into one of two groups. In the intervention group, CPPopt is calculated using a published (modified) algorithm. In the control group, the CPP target recommended in the Brain Trauma Foundation guidelines (CPP 60-70 mmHg) is used. RESULTS Patient recruitment started in February 2018 and will continue until 60 patients have been studied. Fifty-one patients (85% of the intended total) have been recruited in October 2019. The first results are expected early 2021. CONCLUSION This prospective evaluation of the feasibility, safety and physiological implications of autoregulation-guided CPP management is providing evidence that will be useful in the design of a future phase III study in severe TBI patients.
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Affiliation(s)
- Jeanette Tas
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - C R van Kaam
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Ari Ercole
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Gert Bellen
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - D Bruyninckx
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Bart Depreitere
- Department of Neurosciences, Catholic University Leuven, University Hospital Leuven, Leuven, Belgium
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marta Fedriga
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, Cambridge University, Cambridge, UK
| | - D Menon
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - Geert Meyfroidt
- Department of Cellular and Molecular Medicine, Catholic University Leuven, University Hospital, Leuven, Belgium
| | - Annalisa Liberti
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
| | - J G Outtrim
- University Division of Anaesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, UK
| | - C Robba
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - C W E Hoedemaekers
- Department of Intensive Care Medicine, Radboud University Medical Centre, Nijmegen, The Netherlands
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marcel J Aries
- Department of Intensive Care Medicine, University of Maastricht, Maastricht University Medical Centre, Maastricht, The Netherlands
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23
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Deng F, Zhang Y, Zhang R, Tang Q, Guo Z, Lv Y, Wang Z, Yang Y. Compromised Dynamic Cerebral Autoregulation in Patients With Central Disorders of Hypersomnolence. Front Neurol 2021; 12:634660. [PMID: 33776891 PMCID: PMC7991911 DOI: 10.3389/fneur.2021.634660] [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: 11/28/2020] [Accepted: 02/16/2021] [Indexed: 11/18/2022] Open
Abstract
Objective: We aimed to investigate the dynamic cerebral autoregulation (dCA) in patients with central disorders of hypersomnolence during wakefulness. Methods: Thirty-six patients with central disorders of hypersomnolence were divided into three groups according to polysomnography and multiple sleep latency test results: the idiopathic hypersomnia group (IH), narcolepsy type 1 without rapid-eye-movement sleep behavior disorder group (NT1-RBD), and narcolepsy type 1 with rapid-eye-movement sleep behavior disorder group (NT1 + RBD), with 12 patients in each group. Twelve sex- and age-matched healthy controls were recruited. We assessed the Epworth sleepiness scale (ESS) and dCA of all subjects. dCA was assessed by analyzing the phase difference (PD) using transfer function analysis. The ESS and dCA were analyzed before and after standardized treatment in 24 patients with narcolepsy type 1. Results: The overall PD of the IH, NT1-RBD, and NT1 + RBD groups were lower than that of the control group (P < 0.001). There were no significant differences between the overall PD of the NT1-RBD and NT1 + RBD group (P > 0.05). The ESS scores decreased and the overall PD increased after treatment in 24 patients with narcolepsy type 1 (P < 0.001). Multivariable analysis showed that mean sleep latency in multiple sleep latency test was independently associated with impaired overall PD (P < 0.05). Conclusions: The dCA is impaired in patients with central disorders of hypersomnolence. The impairment of dCA occurs irrespective of NT1-RBD/+RBD. The ESS score and dCA improved in patients with narcolepsy type 1 after medication treatment. The mean sleep latency in multiple sleep latency test was independently associated with impaired dCA. Clinical Trial Registration:www.ClinicalTrials.gov, identifier: NCT02752139.
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Affiliation(s)
- Fang Deng
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yanan Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Ran Zhang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Qi Tang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Zhenni Guo
- Department of Neurology, Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
| | - Yudan Lv
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Zan Wang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, Clinical Trial and Research Center for Stroke, The First Hospital of Jilin University, Changchun, China
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24
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de Havenon A, Petersen N, Sultan-Qurraie A, Alexander M, Yaghi S, Park M, Grandhi R, Mistry E. Blood Pressure Management Before, During, and After Endovascular Thrombectomy for Acute Ischemic Stroke. Semin Neurol 2021; 41:46-53. [PMID: 33472269 PMCID: PMC8063274 DOI: 10.1055/s-0040-1722721] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022]
Abstract
There is an absence of specific evidence or guideline recommendations on blood pressure management for large vessel occlusion stroke patients. Until randomized data are available, the periprocedural blood pressure management of patients undergoing endovascular thrombectomy can be viewed in two phases relative to the achievement of recanalization. In the hyperacute phase, prior to recanalization, hypotension should be avoided to maintain adequate penumbral perfusion. The American Heart Association guidelines should be followed for the upper end of prethrombectomy blood pressure: ≤185/110 mm Hg, unless post-tissue plasminogen activator administration when the goal is <180/105 mm Hg. After successful recanalization (thrombolysis in cerebral infarction [TICI]: 2b-3), we recommend a target of a maximum systolic blood pressure of < 160 mm Hg, while the persistently occluded patients (TICI < 2b) may require more permissive goals up to <180/105 mm Hg. Future research should focus on generating randomized data on optimal blood pressure management both before and after endovascular thrombectomy, to optimize patient outcomes for these divergent clinical scenarios.
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Affiliation(s)
- Adam de Havenon
- Department of Neurology, University of Utah, Salt Lake City, Utah
| | - Nils Petersen
- Department of Neurology, Yale University, New Haven, Connecticut
| | - Ali Sultan-Qurraie
- Department of Neurology, University of Washington, Valley Medical Center, Seattle, Washington
| | | | - Shadi Yaghi
- Department of Neurology, New York University, New York, New York
| | - Min Park
- Department of Neurosurgery, University of Virginia, Charlottesville, Virginia
| | - Ramesh Grandhi
- Department of Neurosurgery, University of Utah, Salt Lake City, Utah
| | - Eva Mistry
- Department of Neurology, Vanderbilt University Medical Center, Nashville, Tennessee
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25
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Kreft B, Bergs J, Shahryari M, Danyel LA, Hetzer S, Braun J, Sack I, Tzschätzsch H. Cerebral Ultrasound Time-Harmonic Elastography Reveals Softening of the Human Brain Due to Dehydration. Front Physiol 2021; 11:616984. [PMID: 33505319 PMCID: PMC7830390 DOI: 10.3389/fphys.2020.616984] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/13/2020] [Accepted: 12/09/2020] [Indexed: 01/12/2023] Open
Abstract
Hydration influences blood volume, blood viscosity, and water content in soft tissues - variables that determine the biophysical properties of biological tissues including their stiffness. In the brain, the relationship between hydration and stiffness is largely unknown despite the increasing importance of stiffness as a quantitative imaging marker. In this study, we investigated cerebral stiffness (CS) in 12 healthy volunteers using ultrasound time-harmonic elastography (THE) in different hydration states: (i) during normal hydration, (ii) after overnight fasting, and (iii) within 1 h of drinking 12 ml of water per kg body weight. In addition, we correlated shear wave speed (SWS) with urine osmolality and hematocrit. SWS at normal hydration was 1.64 ± 0.02 m/s and decreased to 1.57 ± 0.04 m/s (p < 0.001) after overnight fasting. SWS increased again to 1.63 ± 0.01 m/s within 30 min of water drinking, returning to values measured during normal hydration (p = 0.85). Urine osmolality at normal hydration (324 ± 148 mOsm/kg) increased to 784 ± 107 mOsm/kg (p < 0.001) after fasting and returned to normal (288 ± 128 mOsm/kg, p = 0.83) after water drinking. SWS and urine osmolality correlated linearly (r = -0.68, p < 0.001), while SWS and hematocrit did not correlate (p = 0.31). Our results suggest that mild dehydration in the range of diurnal fluctuations is associated with significant softening of brain tissue, possibly due to reduced cerebral perfusion. To ensure consistency of results, it is important that cerebral elastography with a standardized protocol is performed during normal hydration.
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Affiliation(s)
- Bernhard Kreft
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Judith Bergs
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Mehrgan Shahryari
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | | | - Stefan Hetzer
- Bernstein Center of Advanced Neuroimaging, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Jürgen Braun
- Institute of Medical Informatics, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Ingolf Sack
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
| | - Heiko Tzschätzsch
- Department of Radiology, Charité-Universitätsmedizin Berlin, Berlin, Germany
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26
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Propofol/Remifentanil Anesthesia Might Not Alter the Middle Cerebral Artery Diameter by Digital Subtraction Angiography. Neurocrit Care 2020; 31:338-345. [PMID: 30877554 DOI: 10.1007/s12028-019-00699-3] [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] [Indexed: 12/15/2022]
Abstract
INTRODUCTION Transcranial Doppler (TCD) of the middle cerebral artery (MCA) enables the measurement of the mean blood velocity (MCAVm) and the estimation of the cerebral blood flow (CBF), provided that no significant changes occur in the MCA diameter (MCADiam). Previous studies described a decrease in the MCAVm associated with the induction of total intravenous anesthesia (TIVA) by propofol and remifentanil. This decrease in blood velocity might be interpreted as a decrease in the CBF only where the MCADiam is not modified across TCD examinations. METHODS In this observational study, we measured the MCADiam of 24 subjects (almost exclusively females) on digital subtraction angiography under awake and TIVA conditions. RESULTS Across the two phases, we observed a decrease in the mean arterial blood pressure (from 84 ± 9 to 71 ± 6 mmHg; p < 0.001) and heart rate (76 ± 10 vs. 65 ± 8 beats/min; p < 0.001), and a concomitant decrease in the MCAVm (61 vs. 42 cm/s; p < 0.001). In contrast, the MCADiam did not vary in association with TIVA (2.3 ± 0.2 vs. 2.3 ± 0.2 mm; p = 0.52). CONCLUSIONS Those results suggested that in this population, no significant changes in the MCADiam are associated with TIVA.
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Robba C, Donnelly J, Cardim D, Tajsic T, Cabeleira M, Citerio G, Pelosi P, Smielewski P, Hutchinson P, Menon DK, Czosnyka M. Optic nerve sheath diameter ultrasonography at admission as a predictor of intracranial hypertension in traumatic brain injured patients: a prospective observational study. J Neurosurg 2020; 132:1279-1285. [PMID: 30849751 DOI: 10.3171/2018.11.jns182077] [Citation(s) in RCA: 23] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/22/2018] [Accepted: 11/19/2018] [Indexed: 01/11/2023]
Abstract
OBJECTIVE Intracranial hypertension and impaired cerebral autoregulation are common causes of secondary injuries in patients with traumatic brain injury (TBI). The primary outcome of this study was to assess whether a noninvasive method to estimate intracranial pressure (ICP) based on the ultrasonography of the optic nerve sheath diameter (ONSD) measured at the time of neurocritical care unit (NCCU) admission is correlated with the mean ICP during NCCU stay. Secondary outcomes were to assess whether ONSD is correlated with the dose of ICP > 20 mm Hg and impaired autoregulation during NCCU stay and with instantaneous ICP and whether ONSD is associated with NCCU mortality. METHODS This prospective observational monocentric study included adults with severe TBI. ONSD was measured at NCCU admission, immediately after invasive ICP insertion. ONSD-predicted noninvasive ICP (nICPONSD) was calculated according the formula: nICPONSD = 5 × ONSD - 14 (nICPONSD in mm Hg, ONSD in mm). Autoregulation was measured using the pressure reactivity index (PRx). RESULTS In total, 100 patients were included in this study. ONSD was significantly correlated with mean ICP (r = 0.46, p < 0.0001), with mean PRx (r = 0.21, p = 0.04), and with the dose of ICP > 20 mm Hg during NCCU stay (r = 0.49, p < 0.0001). Admission nICPONSD was shown to be significantly correlated with instantaneous ICP (r = 0.85, p < 0.001). ONSD at admission was significantly correlated with NCCU mortality (p = 0.02). CONCLUSIONS ONSD measured at NCCU admission can give important information about patients at risk of developing intracranial hypertension and impaired autoregulation. ONSD examination could be useful to screen patients at admission to determine who would benefit from further invasive ICP monitoring.
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Affiliation(s)
- Chiara Robba
- 1Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa, Italy
- 2Neurointensive Care, Addenbrooke's Hospital, and
| | - Joseph Donnelly
- 3Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- 4Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Danilo Cardim
- 3Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- 5Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Tamara Tajsic
- 6Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- 3Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Giuseppe Citerio
- 7School of Medicine and Surgery, University Milan Bicocca Neurointensive Care, Department of Emergency and Intensive Care, San Gerardo Hospital, ASST-Monza, Italy
| | - Paolo Pelosi
- 1Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, University of Genoa, Genoa, Italy
- 8Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy; and
| | - Peter Smielewski
- 3Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Hutchinson
- 6Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | | | - Marek Czosnyka
- 3Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- 9Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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Miller EC, Dos Santos KRM, Marshall RS, Kougioumtzoglou IA. Joint time-frequency analysis of dynamic cerebral autoregulation using generalized harmonic wavelets. Physiol Meas 2020; 41:024002. [PMID: 32000149 DOI: 10.1088/1361-6579/ab71f2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Abstract
OBJECTIVE To develop a joint time-frequency analysis technique based on generalized harmonic wavelets (GHWs) for dynamic cerebral autoregulation (DCA) performance quantification. APPROACH We considered two groups of human subjects to develop and validate the method: 55 healthy volunteers and 35 stroke-free subjects with unilateral internal carotid artery stenosis (CAS). We determined the mean and coherence-weighted average of the phase shift (PS) of appropriately defined GHW-based transfer functions, based on data points over the joint time-frequency domain. We compared agreement of standard transfer function analysis (TFA) and GHW analyses in healthy subjects using Bland-Altman plots. We assessed sensitivity of each metric to detect the presumed side-to-side difference in DCA function in CAS subjects (with decreased PS on the occluded side), using McNemar's chi square test to compare each metric to the standard TFA approach. An alternative Morlet wavelet-based approach was also considered. MAIN RESULTS The GHW and TFA methods exhibited strong agreement in healthy subjects. Among CAS subjects, GHW metrics outperformed TFA and Morlet wavelet-based approaches in identifying expected side-to-side differences: TFA sensitivity was 40.0% (95%CI 23.9-57.9), Morlet 60.0% (95%CI 42.1-76.1), and GHW >70% for both metrics (GHW mean PS sensitivity 74.3, 95%CI 56.7-87.5, p = 0.0027 versus TFA; GHW coherence-weighted PS sensitivity 71.4, 95%CI 53.7-85.4, p = 0.0009 versus TFA). SIGNIFICANCE In comparison to the widely used stationary Fourier transform-based TFA and to Morlet wavelet-based analysis, our data suggest that the GHW-based analysis performs better in identifying DCA asymmetry between the two cerebral hemispheres in patients with high grade unilateral carotid stenosis. Our method may provide enhanced confidence in employing DCA metrics as a sensitive diagnostic tool for detecting impaired DCA function in a variety of pathological settings.
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Affiliation(s)
- E C Miller
- Neurology-Stroke Division, Neurological Institute of New York, Columbia University Irving Medical Center, New York, NY, United States of America. The first two authors contributed equally to this manuscript
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Calviello LA, Czigler A, Zeiler FA, Smielewski P, Czosnyka M. Validation of non-invasive cerebrovascular pressure reactivity and pulse amplitude reactivity indices in traumatic brain injury. Acta Neurochir (Wien) 2020; 162:337-344. [PMID: 31853797 PMCID: PMC6982628 DOI: 10.1007/s00701-019-04169-9] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/18/2019] [Accepted: 12/05/2019] [Indexed: 12/16/2022]
Abstract
BACKGROUND Two transcranial Doppler (TCD) estimators of cerebral arterial blood volume (CaBV) coexist: continuous outflow of arterial blood outside the cranium through a low-pulsatile venous system (continuous flow forward, CFF) and pulsatile outflow through regulating arterioles (pulsatile flow forward, PFF). We calculated non-invasive equivalents of the pressure reactivity index (PRx) and the pulse amplitude index PAx with slow waves of mean CaBV and its pulse amplitude. METHODS About 273 individual TBI patients were retrospectively reviewed. PRx is the correlation coefficient between 30 samples of 10-second averages of ICP and mean ABP. PAx is the correlation coefficient between 30 samples of 10-second averages of the amplitude of ICP (AMP, derived from Fourier analysis of the raw full waveform ICP tracing) and mean ABP. nPRx is calculated with CaBV instead of ICP and nPAx with the pulse amplitude of CaBV instead of AMP (calculated using both the CFF and PFF models). All reactivity indices were additionally compared with Glasgow Outcome Score (GOS) to verify potential outcome-predictive strength. RESULTS When correlated, slow waves of ICP demonstrated good coherence between slow waves in CaBV (>0.75); slow waves of AMP showed good coherence with slow waves of the pulse amplitude of CaBV (>0.67) in both the CFF and PFF models. nPRx was moderately correlated with PRx (R = 0.42 for CFF and R = 0.38 for PFF; p < 0.0001). nPAx correlated with PAx with slightly better strength (R = 0.56 for CFF and R = 0.41 for PFF; p < 0.0001). nPAx_CFF showed the strongest association with outcomes. CONCLUSIONS Non-invasive estimators (nPRx and nPAx) are associated with their invasive counterparts and can provide meaningful associations with outcome after TBI. The CFF model is slightly superior to the PFF model.
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Harris A, Guidoboni G, Siesky B, Mathew S, Verticchio Vercellin AC, Rowe L, Arciero J. Ocular blood flow as a clinical observation: Value, limitations and data analysis. Prog Retin Eye Res 2020; 78:100841. [PMID: 31987983 PMCID: PMC8908549 DOI: 10.1016/j.preteyeres.2020.100841] [Citation(s) in RCA: 41] [Impact Index Per Article: 10.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/02/2019] [Revised: 01/14/2020] [Accepted: 01/16/2020] [Indexed: 12/24/2022]
Abstract
Alterations in ocular blood flow have been identified as important risk factors for the onset and progression of numerous diseases of the eye. In particular, several population-based and longitudinal-based studies have provided compelling evidence of hemodynamic biomarkers as independent risk factors for ocular disease throughout several different geographic regions. Despite this evidence, the relative contribution of blood flow to ocular physiology and pathology in synergy with other risk factors and comorbidities (e.g., age, gender, race, diabetes and hypertension) remains uncertain. There is currently no gold standard for assessing all relevant vascular beds in the eye, and the heterogeneous vascular biomarkers derived from multiple ocular imaging technologies are non-interchangeable and difficult to interpret as a whole. As a result of these disease complexities and imaging limitations, standard statistical methods often yield inconsistent results across studies and are unable to quantify or explain a patient's overall risk for ocular disease. Combining mathematical modeling with artificial intelligence holds great promise for advancing data analysis in ophthalmology and enabling individualized risk assessment from diverse, multi-input clinical and demographic biomarkers. Mechanism-driven mathematical modeling makes virtual laboratories available to investigate pathogenic mechanisms, advance diagnostic ability and improve disease management. Artificial intelligence provides a novel method for utilizing a vast amount of data from a wide range of patient types to diagnose and monitor ocular disease. This article reviews the state of the art and major unanswered questions related to ocular vascular anatomy and physiology, ocular imaging techniques, clinical findings in glaucoma and other eye diseases, and mechanistic modeling predictions, while laying a path for integrating clinical observations with mathematical models and artificial intelligence. Viable alternatives for integrated data analysis are proposed that aim to overcome the limitations of standard statistical approaches and enable individually tailored precision medicine in ophthalmology.
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Affiliation(s)
- Alon Harris
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA.
| | | | - Brent Siesky
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA
| | - Sunu Mathew
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Alice C Verticchio Vercellin
- Department of Ophthalmology, Icahn School of Medicine at Mount Sinai Hospital, New York, NY, USA; University of Pavia, Pavia, Italy; IRCCS - Fondazione Bietti, Rome, Italy
| | - Lucas Rowe
- Indiana University School of Medicine, Indianapolis, IN, USA
| | - Julia Arciero
- Indiana University-Purdue University Indianapolis, Indianapolis, IN, USA
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Robba C, Taccone FS. How I use Transcranial Doppler. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2019; 23:420. [PMID: 31870405 PMCID: PMC6929281 DOI: 10.1186/s13054-019-2700-6] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 12/11/2019] [Indexed: 11/30/2022]
Affiliation(s)
- Chiara Robba
- Policlinico San Martino, IRCCS per l'Oncologia e Neuroscienze, Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università degli Studi di Genova, Genova, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care Medicine, Erasme Hospital, Université Libre de Bruxelles (ULB), Route de Lennik, 808, 1070, Brussels, Belgium.
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Beqiri E, Smielewski P, Robba C, Czosnyka M, Cabeleira MT, Tas J, Donnelly J, Outtrim JG, Hutchinson P, Menon D, Meyfroidt G, Depreitere B, Aries MJ, Ercole A. Feasibility of individualised severe traumatic brain injury management using an automated assessment of optimal cerebral perfusion pressure: the COGiTATE phase II study protocol. BMJ Open 2019; 9:e030727. [PMID: 31542757 PMCID: PMC6756360 DOI: 10.1136/bmjopen-2019-030727] [Citation(s) in RCA: 87] [Impact Index Per Article: 17.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/17/2023] Open
Abstract
INTRODUCTION Individualising therapy is an important challenge for intensive care of patients with severe traumatic brain injury (TBI). Targeting a cerebral perfusion pressure (CPP) tailored to optimise cerebrovascular autoregulation has been suggested as an attractive strategy on the basis of a large body of retrospective observational data. The objective of this study is to prospectively assess the feasibility and safety of such a strategy compared with fixed thresholds which is the current standard of care from international consensus guidelines. METHODS AND ANALYSIS CPPOpt Guided Therapy: Assessment of Target Effectiveness (COGiTATE) is a prospective, multicentre, non-blinded randomised, controlled trial coordinated from Maastricht University Medical Center, Maastricht (The Netherlands). The other original participating centres are Cambridge University NHS Foundation Trust, Cambridge (UK), and University Hospitals Leuven, Leuven (Belgium). Adult severe TBI patients requiring intracranial pressure monitoring are randomised within the first 24 hours of admission in neurocritical care unit. For the control arm, the CPP target is the Brain Trauma Foundation guidelines target (60-70 mm Hg); for the intervention group an automated CPP target is provided as the CPP at which the patient's cerebrovascular reactivity is best preserved (CPPopt). For a maximum of 5 days, attending clinicians review the CPP target 4-hourly. The main hypothesis of COGiTATE are: (1) in the intervention group the percentage of the monitored time with measured CPP within a range of 5 mm Hg above or below CPPopt will reach 36%; (2) the difference in between groups in daily therapy intensity level score will be lower or equal to 3. ETHICS AND DISSEMINATION Ethical approval has been obtained for each participating centre. The results will be presented at international scientific conferences and in peer-reviewed journals. TRIAL REGISTRATION NUMBER NCT02982122.
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Affiliation(s)
- Erta Beqiri
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
- Physiology and Transplantation, University of Milan, Milano, Italy
| | | | - Chiara Robba
- Anaesthesia and Intensive Care,Policlinico San Martino, IRCCS for Oncology and Neuroscience, University of Genoa, Genova, Italy
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | - Jeanette Tas
- Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, UK
| | | | | | - David Menon
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Intensieve geneeskunde, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Bart Depreitere
- Intensieve geneeskunde, Universitaire Ziekenhuizen Leuven, Leuven, Belgium
| | - Marcel J Aries
- Intensive Care, Maastricht Universitair Medisch Centrum+, Maastricht, The Netherlands
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
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Zhang Z, Pu Y, Mi D, Liu L. Cerebral Hemodynamic Evaluation After Cerebral Recanalization Therapy for Acute Ischemic Stroke. Front Neurol 2019; 10:719. [PMID: 31333570 PMCID: PMC6618680 DOI: 10.3389/fneur.2019.00719] [Citation(s) in RCA: 23] [Impact Index Per Article: 4.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/14/2018] [Accepted: 06/18/2019] [Indexed: 12/14/2022] Open
Abstract
Cerebral recanalization therapy, either intravenous thrombolysis or mechanical thrombectomy, improves the outcomes in patients with acute ischemic stroke (AIS) by restoring the cerebral perfusion of the ischemic penumbra. Cerebral hemodynamic evaluation after recanalization therapy, can help identify patients with high risks of reperfusion-associated complications. Among the various hemodynamic modalities, magnetic resonance imaging (MRI), computed tomography perfusion, and transcranial Doppler sonography (TCD) are the most commonly used. Poststroke hypoperfusion is associated with infarct expansion, while hyperperfusion, which once was considered the hallmark of successful recanalization, is associated with hemorrhagic transformation. Either the hypo- or the hyperperfusion may result in poor clinical outcomes. Individual blood pressure target based on cerebral hemodynamic evaluation was crucial to improve the prognosis. This review summarizes literature on cerebral hemodynamic evaluation and management after recanalization therapy to guide clinical decision making.
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Affiliation(s)
- Zhe Zhang
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Yuehua Pu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Donghua Mi
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
| | - Liping Liu
- Department of Neurology, Beijing Tiantan Hospital, Capital Medical University, Beijing, China
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Donnelly J, Czosnyka M, Adams H, Cardim D, Kolias AG, Zeiler FA, Lavinio A, Aries M, Robba C, Smielewski P, Hutchinson PJA, Menon DK, Pickard JD, Budohoski KP. Twenty-Five Years of Intracranial Pressure Monitoring After Severe Traumatic Brain Injury: A Retrospective, Single-Center Analysis. Neurosurgery 2018; 85:E75-E82. [DOI: 10.1093/neuros/nyy468] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/11/2018] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
Intracranial pressure (ICP) is a clinically important variable after severe traumatic brain injury (TBI) and has been monitored, along with clinical outcome, for over 25 yr in Addenbrooke's hospital, Cambridge, United Kingdom. This time period has also seen changes in management strategies with the implementation of protocolled specialist neurocritical care, expansion of neuromonitoring techniques, and adjustments of clinical treatment targets.
OBJECTIVE
To describe the changes in intracranial monitoring variables over the past 25 yr.
METHODS
Data from 1146 TBI patients requiring ICP monitoring were analyzed. Monitored variables included ICP, cerebral perfusion pressure (CPP), and the cerebral pressure reactivity index (PRx). Data were stratified into 5-yr epochs spanning the 25 yr from 1992 to 2017.
RESULTS
CPP increased sharply with specialist neurocritical care management (P < 0.0001) (introduction of a specific TBI management algorithm) before stabilizing from 2000 onwards. ICP decreased significantly over the 25 yr of monitoring from an average of 19 to 12 mmHg (P < 0.0001) but PRx remained unchanged. The mean number of ICP plateau waves and the number of patients developing refractory intracranial hypertension both decreased significantly. Mortality did not significantly change in the cohort (22%).
CONCLUSION
We demonstrate the evolving trends in neurophysiological monitoring over the past 25 yr from a single, academic neurocritical care unit. ICP and CPP were responsive to the introduction of an ICP/CPP protocol while PRx has remained unchanged.
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Affiliation(s)
- Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Hadie Adams
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Angelos G Kolias
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A Zeiler
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Andrea Lavinio
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Marcel Aries
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Chiara Robba
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J A Hutchinson
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - John D Pickard
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Karol P Budohoski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Abstract
PURPOSE OF THE REVIEW To discuss the diagnostic approach to patients with septic encephalopathy as well as the need for specific neuro-monitoring and the perspectives on future therapeutic approaches in this setting. RECENT FINDINGS Most of data-concern experimental studies evaluating the pathophysiology of septic encephalopathy. A combination of neurodegenerative pathways with neurovascular injury is the cornerstone for the development of such complication and the long-term neurological sequelae among survivors. Septic encephalopathy is a common complication in septic patients. Clinical presentation may range from mild confusion and disorientation to convulsions and deep coma. The diagnosis of septic encephalopathy is made difficult by the lack of any specific clinical and non-clinical feature, in particular among sedated patients in whom neurological examination is unreliable. In spite of the high mortality rate associated with this condition, there is no prophylactic or targeted therapy to reduce or minimize brain damage in septic patients and clinical management is limited to the treatment of the underlying infection.
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Gadda G, Majka M, Zieliński P, Gambaccini M, Taibi A. A multiscale model for the simulation of cerebral and extracerebral blood flows and pressures in humans. Eur J Appl Physiol 2018; 118:2443-2454. [DOI: 10.1007/s00421-018-3971-3] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/20/2018] [Accepted: 08/21/2018] [Indexed: 01/26/2023]
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Andersen AV, Simonsen SA, Schytz HW, Iversen HK. Assessing low-frequency oscillations in cerebrovascular diseases and related conditions with near-infrared spectroscopy: a plausible method for evaluating cerebral autoregulation? NEUROPHOTONICS 2018; 5:030901. [PMID: 30689678 PMCID: PMC6156398 DOI: 10.1117/1.nph.5.3.030901] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/16/2018] [Accepted: 08/02/2018] [Indexed: 05/08/2023]
Abstract
BACKGROUND Cerebral autoregulation (CA) is the brain's ability to always maintain an adequate and relatively constant blood supply, which is often impaired in cerebrovascular diseases. Near-infrared spectroscopy (NIRS) examines oxygenated hemoglobin (OxyHb) in the cerebral cortex. Low- and very low-frequency oscillations ( LFOs ≈ 0.1 Hz and VLFOs ≈ 0.05 to 0.01 Hz) in OxyHb have been proposed to reflect CA. AIM To systematically review published results on OxyHb LFOs and VLFOs in cerebrovascular diseases and related conditions measured with NIRS. APPROACH A systematic search was performed in the MEDLINE database, which generated 36 studies relevant for inclusion. RESULTS Healthy people have relatively stable LFOs. LFO amplitude seems to reflect myogenic CA being decreased by vasomotor paralysis in stroke, by smooth muscle damage or as compensatory action in other conditions but can also be influenced by the sympathetic tone. VLFO amplitude is believed to reflect neurogenic and metabolic CA and is lower in stroke, atherosclerosis, and with aging. Both LFO and VLFO synchronizations appear disturbed in stroke, while the former is also altered in internal carotid stenosis and hypertension. CONCLUSION We conclude that amplitudes of LFOs and VLFOs are relatively robust measures for evaluating mechanisms of CA and synchronization analyses can show temporal disruption of CA. Further research and more coherent methodologies are needed.
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Affiliation(s)
- Adam Vittrup Andersen
- Rigshospitalet, Department of Neurology, Glostrup, Denmark
- University of Copenhagen, Department of Clinical Medicine, Copenhagen, Denmark
- Address all correspondence to: Adam Vittrup Andersen, E-mail:
| | - Sofie Amalie Simonsen
- Rigshospitalet, Department of Neurology, Glostrup, Denmark
- University of Copenhagen, Department of Clinical Medicine, Copenhagen, Denmark
| | - Henrik Winther Schytz
- Rigshospitalet, Department of Neurology, Glostrup, Denmark
- University of Copenhagen, Department of Clinical Medicine, Copenhagen, Denmark
| | - Helle Klingenberg Iversen
- Rigshospitalet, Department of Neurology, Glostrup, Denmark
- University of Copenhagen, Department of Clinical Medicine, Copenhagen, Denmark
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Doerfler S, Faerber J, McKhann GM, Elliott JP, Winn HR, Kumar M, Levine J, Le Roux PD. The Incidence and Impact of Secondary Cerebral Insults on Outcome After Aneurysmal Subarachnoid Hemorrhage. World Neurosurg 2018; 114:e483-e494. [DOI: 10.1016/j.wneu.2018.02.195] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/06/2017] [Revised: 02/25/2018] [Accepted: 02/28/2018] [Indexed: 02/04/2023]
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Abstract
PURPOSE OF REVIEW The purpose of this review is to briefly describe the concept of cerebral autoregulation, to detail several bedside techniques for measuring and assessing autoregulation, and to outline the impact of impaired autoregulation on clinical and functional outcomes in acute brain injury. Furthermore, we will review several autoregulation studies in select forms of acute brain injuries, discuss the potential for its use in patient management in the ICU, and suggest further avenues for research. RECENT FINDINGS Cerebral autoregulation plays a critical role in regulating cerebral blood flow, and impaired autoregulation has been associated with worse functional and clinical outcomes in various acute brain injuries. There exists a multitude of methods to assess the autoregulatory state in patients using both invasive and non-invasive modalities. Continuous monitoring of patients in the ICU has yielded autoregulatory-derived optimal perfusion pressures that may prevent secondary injury and improve outcomes. Measuring autoregulation continuously at the bedside is now a feasible option for clinicians working in the ICU, although there exists a great need to standardize autoregulatory measurement. While the clinical benefits await prospective and randomized trials, autoregulation-derived parameters show enormous potential for creating an optimal physiological environment for the injured brain.
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Affiliation(s)
- Anson Wang
- Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA
| | | | - Nils H Petersen
- Department of Neurology, Yale School of Medicine, PO Box 208018, New Haven, CT, 06520, USA.
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Skytioti M, Søvik S, Elstad M. Dynamic cerebral autoregulation is preserved during isometric handgrip and head-down tilt in healthy volunteers. Physiol Rep 2018; 6:e13656. [PMID: 29595918 PMCID: PMC5875546 DOI: 10.14814/phy2.13656] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/28/2017] [Revised: 02/20/2018] [Accepted: 02/26/2018] [Indexed: 12/29/2022] Open
Abstract
In healthy humans, cerebral blood flow (CBF) is autoregulated against changes in arterial blood pressure. Spontaneous fluctuations in mean arterial pressure (MAP) and CBF can be used to assess cerebral autoregulation. We hypothesized that dynamic cerebral autoregulation is affected by changes in autonomic activity, MAP, and cardiac output (CO) induced by handgrip (HG), head‐down tilt (HDT), and their combination. In thirteen healthy volunteers, we recorded blood velocity by ultrasound in the internal carotid artery (ICA), HR, MAP and CO‐estimates from continuous finger blood pressure, and end‐tidal CO2. Instantaneous ICA beat volume (ICABV, mL) and ICA blood flow (ICABF, mL/min) were calculated. Wavelet synchronization index γ (0–1) was calculated for the pairs: MAP–ICABF, CO–ICABF and HR–ICABV in the low (0.05–0.15 Hz; LF) and high (0.15–0.4 Hz; HF) frequency bands. ICABF did not change between experimental states. MAP and CO were increased during HG (+16% and +15%, respectively, P < 0.001) and during HDT + HG (+12% and +23%, respectively, P < 0.001). In the LF interval, median γ for the MAP–ICABF pair (baseline: 0.23 [0.12–0.28]) and the CO–ICABF pair (baseline: 0.22 [0.15–0.28]) did not change with HG, HDT, or their combination. High γ was observed for the HR–ICABV pair at the respiratory frequency, the oscillations in these variables being in inverse phase. The unaltered ICABF and the low synchronization between MAP and ICABF in the LF interval suggest intact dynamic cerebral autoregulation during HG, HDT, and their combination.
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Affiliation(s)
- Maria Skytioti
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
| | - Signe Søvik
- Institute of Clinical Medicine, Faculty of Medicine, University of Oslo, Oslo, Norway.,Department of Anaesthesia and Intensive Care, Akershus University Hospital, Lørenskog, Norway
| | - Maja Elstad
- Division of Physiology, Institute of Basic Medical Sciences, University of Oslo, Oslo, Norway
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Multimodality neuromonitoring in severe pediatric traumatic brain injury. Pediatr Res 2018; 83:41-49. [PMID: 29084196 DOI: 10.1038/pr.2017.215] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/22/2016] [Accepted: 08/31/2017] [Indexed: 12/18/2022]
Abstract
Each year, the annual hospitalization rates of traumatic brain injury (TBI) in children in the United States are 57.7 per 100K in the <5 years of age and 23.1 per 100K in the 5-14 years age group. Despite this, little is known about the pathophysiology of TBI in children and how to manage it most effectively. Historically, TBI management has been guided by clinical examination. This has been assisted progressively by clinical imaging, intracranial pressure (ICP) monitoring, and finally a software that can calculate optimal brain physiology. Multimodality monitoring affords clinicians an early indication of secondary insults to the recovering brain including raised ICP and decreased cerebral perfusion pressure. From variables such as ICP and arterial blood pressure, correlations can be drawn to determine parameters of cerebral autoregulation (pressure reactivity index) and "optimal cerebral perfusion pressure" at which the vasculature is most reactive. More recently, significant advances using both direct and near-infrared spectroscopy-derived brain oxygenation plus cerebral microdialysis to drive management have been described. Here in, we provide a perspective on the state-of-the-art techniques recently implemented in clinical practice for pediatric TBI.
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Pressure Reactivity-Based Optimal Cerebral Perfusion Pressure in a Traumatic Brain Injury Cohort. ACTA NEUROCHIRURGICA SUPPLEMENT 2018; 126:209-212. [DOI: 10.1007/978-3-319-65798-1_43] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
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Zeiler FA, Donnelly J, Calviello L, Smielewski P, Menon DK, Czosnyka M. Pressure Autoregulation Measurement Techniques in Adult Traumatic Brain Injury, Part II: A Scoping Review of Continuous Methods. J Neurotrauma 2017; 34:3224-3237. [PMID: 28699412 DOI: 10.1089/neu.2017.5086] [Citation(s) in RCA: 59] [Impact Index Per Article: 8.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022] Open
Abstract
A scoping review of the literature was performed systematically on commonly described continuous autoregulation measurement techniques in adult traumatic brain injury (TBI) to provide an overview of methodology and comprehensive reference library of the available literature for each technique. Five separate small systematic reviews were conducted for each of the continuous techniques: pressure reactivity index (PRx), laser Doppler flowmetry (LDF), near infrared spectroscopy (NIRS) techniques, brain tissue oxygen tension (PbtO2), and thermal diffusion (TD) techniques. Articles from MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to December 2016), and reference lists of relevant articles were searched. A two-tier filter of references was conducted. The literature base identified from the individual searches was limited, except for PRx. The total number of articles using each of the five searched techniques for continuous autoregulation in adult TBI were: PRx (28), LDF (4), NIRS (9), PbtO2 (10), and TD (8). All continuous techniques described in adult TBI are based on moving correlation coefficients. The premise behind the calculation of these moving correlation coefficients focuses on the impact of slow fluctuations in either mean arterial pressure (MAP) or cerebral perfusion pressure (CPP) on some indirect measure of cerebral blood flow (CBF), such as: intracranial pressure (ICP), LDF, NIRS signals, PbtO2, or TD CBF. The thought is the correlation between a hemodynamic driving factor, such as MAP or CPP, and a surrogate for CBF or cerebral perfusion sheds insight on the state of cerebral autoregulation. Both PRx and NIRS indices were validated experimentally against the "gold standard" static autoregulatory curve (Lassen curve) at least around the lower threshold of autoregulation. The PRx has the largest literature base supporting the association with patient outcome. Various methods of continuous autoregulation assessment are described within the adult TBI literature. Many studies exist on these various indices, suggesting an association between their values and patient morbidity/death.
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Affiliation(s)
- Frederick A Zeiler
- 1 Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom .,2 Section of Neurosurgery, Department of Surgery, University of Manitoba , Winnipeg, Manitoba, Canada .,3 Clinician Investigator Program, University of Manitoba , Winnipeg, Manitoba, Canada
| | - Joseph Donnelly
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Leanne Calviello
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Peter Smielewski
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - David K Menon
- 1 Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Marek Czosnyka
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
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Robba C, Cardim D, Sekhon M, Budohoski K, Czosnyka M. Transcranial Doppler: a stethoscope for the brain-neurocritical care use. J Neurosci Res 2017; 96:720-730. [PMID: 28880397 DOI: 10.1002/jnr.24148] [Citation(s) in RCA: 60] [Impact Index Per Article: 8.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2017] [Revised: 06/12/2017] [Accepted: 08/10/2017] [Indexed: 02/03/2023]
Abstract
Transcranial Doppler (TCD) ultrasonography is a noninvasive bedside monitoring technique that can evaluate cerebral blood flow hemodynamics in the intracranial arterial vasculature. TCD allows assessment of linear cerebral blood flow velocity, with a high temporal resolution and is inexpensive, reproducible, and portable. The aim of this review is to provide an overview of the most commonly used TCD derived signals and measurements used commonly in neurocritical care. We describe both basic (flow velocity, pulsatility index) and advanced concepts, including critical closing pressure, wall tension, autoregulation, noninvasive intracranial pressure, brain compliance, and cerebrovascular time constant; we also describe the clinical applications of TCD to highlight their utility in the diagnosis and monitoring of cerebrovascular diseases as the "stethoscope for the brain."
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Affiliation(s)
- Chiara Robba
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge University, Box 1, Addenbrooke's Hospital, Cambridge University Hospitals Trust, Hills Road, Cambridge, CB2 0QQ.,Division of Neuroscience, University of Genoa, Genoa, Italy
| | - Danilo Cardim
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, British Columbia
| | - Karol Budohoski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Donnelly J, Czosnyka M, Adams H, Robba C, Steiner LA, Cardim D, Cabella B, Liu X, Ercole A, Hutchinson PJ, Menon DK, Aries MJH, Smielewski P. Individualizing Thresholds of Cerebral Perfusion Pressure Using Estimated Limits of Autoregulation. Crit Care Med 2017; 45:1464-1471. [PMID: 28816837 PMCID: PMC5595234 DOI: 10.1097/ccm.0000000000002575] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES In severe traumatic brain injury, cerebral perfusion pressure management based on cerebrovascular pressure reactivity index has the potential to provide a personalized treatment target to improve patient outcomes. So far, the methods have focused on identifying "one" autoregulation-guided cerebral perfusion pressure target-called "cerebral perfusion pressure optimal". We investigated whether a cerebral perfusion pressure autoregulation range-which uses a continuous estimation of the "lower" and "upper" cerebral perfusion pressure limits of cerebrovascular pressure autoregulation (assessed with pressure reactivity index)-has prognostic value. DESIGN Single-center retrospective analysis of prospectively collected data. SETTING The neurocritical care unit at a tertiary academic medical center. PATIENTS Data from 729 severe traumatic brain injury patients admitted between 1996 and 2016 were used. Treatment was guided by controlling intracranial pressure and cerebral perfusion pressure according to a local protocol. INTERVENTIONS None. METHODS AND MAIN RESULTS Cerebral perfusion pressure-pressure reactivity index curves were fitted automatically using a previously published curve-fitting heuristic from the relationship between pressure reactivity index and cerebral perfusion pressure. The cerebral perfusion pressure values at which this "U-shaped curve" crossed the fixed threshold from intact to impaired pressure reactivity (pressure reactivity index = 0.3) were denoted automatically the "lower" and "upper" cerebral perfusion pressure limits of reactivity, respectively. The percentage of time with cerebral perfusion pressure below (%cerebral perfusion pressure < lower limit of reactivity), above (%cerebral perfusion pressure > upper limit of reactivity), or within these reactivity limits (%cerebral perfusion pressure within limits of reactivity) was calculated for each patient and compared across dichotomized Glasgow Outcome Scores. After adjusting for age, initial Glasgow Coma Scale, and mean intracranial pressure, percentage of time with cerebral perfusion pressure less than lower limit of reactivity was associated with unfavorable outcome (odds ratio %cerebral perfusion pressure < lower limit of reactivity, 1.04; 95% CI, 1.02-1.06; p < 0.001) and mortality (odds ratio, 1.06; 95% CI, 1.04-1.08; p < 0.001). CONCLUSIONS Individualized autoregulation-guided cerebral perfusion pressure management may be a plausible alternative to fixed cerebral perfusion pressure threshold management in severe traumatic brain injury patients. Prospective randomized research will help define which autoregulation-guided method is beneficial, safe, and most practical.
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Affiliation(s)
- Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Hadie Adams
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Neuroscience, University of Genoa, Italy
| | - Luzius A Steiner
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel Switzerland
| | - Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Brenno Cabella
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Xiuyun Liu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marcel JH Aries
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
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Liu X, Donnelly J, Czosnyka M, Aries MJH, Brady K, Cardim D, Robba C, Cabeleira M, Kim DJ, Haubrich C, Hutchinson PJ, Smielewski P. Cerebrovascular pressure reactivity monitoring using wavelet analysis in traumatic brain injury patients: A retrospective study. PLoS Med 2017; 14:e1002348. [PMID: 28742798 PMCID: PMC5526510 DOI: 10.1371/journal.pmed.1002348] [Citation(s) in RCA: 42] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Accepted: 06/07/2017] [Indexed: 11/18/2022] Open
Abstract
BACKGROUND After traumatic brain injury (TBI), the ability of cerebral vessels to appropriately react to changes in arterial blood pressure (pressure reactivity) is impaired, leaving patients vulnerable to cerebral hypo- or hyperperfusion. Although, the traditional pressure reactivity index (PRx) has demonstrated that impaired pressure reactivity is associated with poor patient outcome, PRx is sometimes erratic and may not be reliable in various clinical circumstances. Here, we introduce a more robust transform-based wavelet pressure reactivity index (wPRx) and compare its performance with the widely used traditional PRx across 3 areas: its stability and reliability in time, its ability to give an optimal cerebral perfusion pressure (CPPopt) recommendation, and its relationship with patient outcome. METHODS AND FINDINGS Five hundred and fifteen patients with TBI admitted in Addenbrooke's Hospital, United Kingdom (March 23rd, 2003 through December 9th, 2014), with continuous monitoring of arterial blood pressure (ABP) and intracranial pressure (ICP), were retrospectively analyzed to calculate the traditional PRx and a novel wavelet transform-based wPRx. wPRx was calculated by taking the cosine of the wavelet transform phase-shift between ABP and ICP. A time trend of CPPopt was calculated using an automated curve-fitting method that determined the cerebral perfusion pressure (CPP) at which the pressure reactivity (PRx or wPRx) was most efficient (CPPopt_PRx and CPPopt_wPRx, respectively). There was a significantly positive relationship between PRx and wPRx (r = 0.73), and wavelet wPRx was more reliable in time (ratio of between-hour variance to total variance, wPRx 0.957 ± 0.0032 versus PRx and 0.949 ± 0.047 for PRx, p = 0.002). The 2-hour interval standard deviation of wPRx (0.19 ± 0.07) was smaller than that of PRx (0.30 ± 0.13, p < 0.001). wPRx performed better in distinguishing between mortality and survival (the area under the receiver operating characteristic [ROC] curve [AUROC] for wPRx was 0.73 versus 0.66 for PRx, p = 0.003). The mean difference between the patients' CPP and their CPPopt was related to outcome for both calculation methods. There was a good relationship between the 2 CPPopts (r = 0.814, p < 0.001). CPPopt_wPRx was more stable than CPPopt_PRx (within patient standard deviation 7.05 ± 3.78 versus 8.45 ± 2.90; p < 0.001). Key limitations include that this study is a retrospective analysis and only compared wPRx with PRx in the cohort of patients with TBI. Prior prospective validation is required to better assess clinical utility of this approach. CONCLUSIONS wPRx offers several advantages to the traditional PRx: it is more stable in time, it yields a more consistent CPPopt recommendation, and, importantly, it has a stronger relationship with patient outcome. The clinical utility of wPRx should be explored in prospective studies of critically injured neurological patients.
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Affiliation(s)
- Xiuyun Liu
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- * E-mail:
| | - Joseph Donnelly
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Marcel J. H. Aries
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Ken Brady
- Baylor College of Medicine, Houston, Texas, United States of America
| | - Danilo Cardim
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Chiara Robba
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Neuroscience, University of Genova, Genova, Italy
| | - Manuel Cabeleira
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Dong-Joo Kim
- Department of Brain & Cognitive Engineering, Korea University, Seoul, South Korea
| | | | - Peter J. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
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Donnelly J, Czosnyka M, Harland S, Varsos GV, Cardim D, Robba C, Liu X, Ainslie PN, Smielewski P. Cerebral haemodynamics during experimental intracranial hypertension. J Cereb Blood Flow Metab 2017; 37:694-705. [PMID: 26994043 PMCID: PMC5381462 DOI: 10.1177/0271678x16639060] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
Intracranial hypertension is a common final pathway in many acute neurological conditions. However, the cerebral haemodynamic response to acute intracranial hypertension is poorly understood. We assessed cerebral haemodynamics (arterial blood pressure, intracranial pressure, laser Doppler flowmetry, basilar artery Doppler flow velocity, and vascular wall tension) in 27 basilar artery-dependent rabbits during experimental (artificial CSF infusion) intracranial hypertension. From baseline (∼9 mmHg; SE 1.5) to moderate intracranial pressure (∼41 mmHg; SE 2.2), mean flow velocity remained unchanged (47 to 45 cm/s; p = 0.38), arterial blood pressure increased (88.8 to 94.2 mmHg; p < 0.01), whereas laser Doppler flowmetry and wall tension decreased (laser Doppler flowmetry 100 to 39.1% p < 0.001; wall tension 19.3 to 9.8 mmHg, p < 0.001). From moderate to high intracranial pressure (∼75 mmHg; SE 3.7), both mean flow velocity and laser Doppler flowmetry decreased (45 to 31.3 cm/s p < 0.001, laser Doppler flowmetry 39.1 to 13.3%, p < 0.001), arterial blood pressure increased still further (94.2 to 114.5 mmHg; p < 0.001), while wall tension was unchanged (9.7 to 9.6 mmHg; p = 0.35).This animal model of acute intracranial hypertension demonstrated two intracranial pressure-dependent cerebroprotective mechanisms: with moderate increases in intracranial pressure, wall tension decreased, and arterial blood pressure increased, while with severe increases in intracranial pressure, an arterial blood pressure increase predominated. Clinical monitoring of such phenomena could help individualise the management of neurocritical patients.
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Affiliation(s)
- Joseph Donnelly
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK.,2 Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | | | - Georgios V Varsos
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Danilo Cardim
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Xiuyun Liu
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Philip N Ainslie
- 4 Centre for Heart, Lung and Vascular Health, School of Health and Exercise Sciences, University of British Columbia, Okanagan, Kelowna, British Columbia, Canada
| | - Peter Smielewski
- 1 Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
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Weigl W, Milej D, Janusek D, Wojtkiewicz S, Sawosz P, Kacprzak M, Gerega A, Maniewski R, Liebert A. Application of optical methods in the monitoring of traumatic brain injury: A review. J Cereb Blood Flow Metab 2016; 36:1825-1843. [PMID: 27604312 PMCID: PMC5094301 DOI: 10.1177/0271678x16667953] [Citation(s) in RCA: 49] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2016] [Revised: 06/28/2016] [Accepted: 07/18/2016] [Indexed: 01/19/2023]
Abstract
We present an overview of the wide range of potential applications of optical methods for monitoring traumatic brain injury. The MEDLINE database was electronically searched with the following search terms: "traumatic brain injury," "head injury," or "head trauma," and "optical methods," "NIRS," "near-infrared spectroscopy," "cerebral oxygenation," or "cerebral oximetry." Original reports concerning human subjects published from January 1980 to June 2015 in English were analyzed. Fifty-four studies met our inclusion criteria. Optical methods have been tested for detection of intracranial lesions, monitoring brain oxygenation, assessment of brain perfusion, and evaluation of cerebral autoregulation or intracellular metabolic processes in the brain. Some studies have also examined the applicability of optical methods during the recovery phase of traumatic brain injury . The limitations of currently available optical methods and promising directions of future development are described in this review. Considering the outstanding technical challenges, the limited number of patients studied, and the mixed results and opinions gathered from other reviews on this subject, we believe that optical methods must remain primarily research tools for the present. More studies are needed to gain confidence in the use of these techniques for neuromonitoring of traumatic brain injury patients.
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Affiliation(s)
- Wojciech Weigl
- Department of Surgical Sciences/Anaesthesiology and Intensive Care, Uppsala University, Akademiska Hospital, Uppsala, Sweden
| | - Daniel Milej
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Dariusz Janusek
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Stanisław Wojtkiewicz
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Piotr Sawosz
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Michał Kacprzak
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Anna Gerega
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Roman Maniewski
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
| | - Adam Liebert
- Nalecz Institute of Biocybernetics and Biomedical Engineering, Polish Academy of Sciences, Warsaw, Poland
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Addison PS. Identifying stable phase coupling associated with cerebral autoregulation using the synchrosqueezed cross-wavelet transform and low oscillation morlet wavelets. ANNUAL INTERNATIONAL CONFERENCE OF THE IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. IEEE ENGINEERING IN MEDICINE AND BIOLOGY SOCIETY. ANNUAL INTERNATIONAL CONFERENCE 2016; 2015:5960-3. [PMID: 26737649 DOI: 10.1109/embc.2015.7319749] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/09/2022]
Abstract
A novel method of identifying stable phase coupling behavior of two signals within the wavelet transform time-frequency plane is presented. The technique employs the cross-wavelet transform to provide a map of phase coupling followed by synchrosqueezing to collect the stable phase regime information. The resulting synchrosqueezed cross-wavelet transform method (Synchro-CrWT) is illustrated using a synthetic signal and then applied to the analysis of the relationship between biosignals used in the analysis of cerebral autoregulation function.
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Addison PS, Antunes A, Montgomery D, Borg UR. Gradient adjustment method for better discriminating correlating and non-correlating regions of physiological signals: application to the partitioning of impaired and intact zones of cerebral autoregulation. J Clin Monit Comput 2016; 31:727-737. [PMID: 27496051 PMCID: PMC5500687 DOI: 10.1007/s10877-016-9913-x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/26/2016] [Accepted: 07/25/2016] [Indexed: 11/10/2022]
Abstract
Cerebral blood flow (CBF) is regulated over a range of systemic blood pressures by the cerebral autoregulation (CA) control mechanism. This range lies within the lower and upper limits of autoregulation (LLA, ULA), beyond which blood pressure drives CBF, and CA function is considered impaired. A standard method to determine autoregulation limits noninvasively using NIRS technology is via the COx measure: a moving correlation index between mean arterial pressure and regional oxygen saturation. In the intact region, there should be no correlation between these variables whereas in the impaired region, the correlation index should approximate unity. In practice, however, the data may be noisy and/or the intact region may often exhibit a slightly positive relationship. This positive relationship may render traditional autoregulation limit calculations difficult to perform, resulting in the need for manual interpretation of the data using arbitrary thresholds. Further, the underlying mathematics of the technique are asymmetric in terms of the results produced for impaired and intact regions and are, in fact, not computable for the ideal case within the intact region. In this work, we propose a novel gradient adjustment method (GACOx) to enhance the differences in COx values observed in the intact and impaired regions. Results from a porcine model (N = 8) are used to demonstrate that GACOx is successful in determining LLA values where traditional methods fail. It is shown that the derived GACOx indices exhibit a mean difference between the intact/impaired regions of 1.54 ± 0.26 (mean ± SD), compared to 0.14 ± 0.10 for the traditional COx method. The GACOx effectively polarizes the COx data in order to better differentiate the intact and impaired zones and, in doing so, makes the determination of the LLA and ULA points a simpler and more consistent task. The method lends itself to the automation of the robust determination of autoregulation zone limits.
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Affiliation(s)
- Paul S Addison
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK.
| | - André Antunes
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK
| | - Dean Montgomery
- Medtronic Respiratory and Monitoring Solutions, Edinburgh, Scotland, UK
| | - Ulf R Borg
- Medtronic Respiratory and Monitoring Solutions, Boulder, CO, USA
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