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Santana LS, Diniz JBC, Solla DJF, Neville IS, Figueiredo EG, Mota Telles JP. Brain tissue oxygen combined with intracranial pressure monitoring versus isolated intracranial pressure monitoring in patients with traumatic brain injury: an updated systematic review and meta-analysis. Neurol Sci 2024; 45:3051-3059. [PMID: 38353849 DOI: 10.1007/s10072-024-07392-0] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/03/2023] [Accepted: 02/05/2024] [Indexed: 06/15/2024]
Abstract
Monitoring intracranial pressure (ICP) is pivotal in the management of severe traumatic brain injury (TBI), but secondary brain injuries can arise despite normal ICP levels. Cerebral tissue oxygenation monitoring (PbtO2) may detect neuronal tissue infarction thresholds, enhancing neuroprotection. We performed a systematic review and meta-analysis to evaluate the effects of combined cerebral tissue oxygenation (PbtO2) and ICP compared to isolated ICP monitoring in patients with TBI. PubMed, Embase, Cochrane, and Web of Sciences databases were searched for trials published up to June 2023. A total of 16 studies comprising 37,820 patients were included. ICP monitoring was universal, with additional placement of PbtO2 in 2222 individuals (5.8%). The meta-analysis revealed a reduction in mortality (OR 0.57, 95% CI 0.37-0.89, p = 0.01), a greater likelihood of favorable outcomes (OR 2.28, 95% CI 1.66-3.14, p < 0.01), and a lower chance of poor outcomes (OR 0.51, 95% CI 0.34-0.79, p < 0.01) at 6 months for the PbtO2 plus ICP group. However, these patients experienced a longer length of hospital stay (MD 2.35, 95% CI 0.50-4.20, p = 0.01). No significant difference was found in hospital mortality rates (OR 0.81, 95% CI 0.61-1.08, p = 0.16) or intensive care unit length of stay (MD 2.46, 95% CI - 0.11-5.04, p = 0.06). The integration of PbtO2 to ICP monitoring improved mortality outcomes and functional recovery at 6 months in patients with TBI. PROSPERO (International Prospective Register of Systematic Reviews) CRD42022383937; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=383937.
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Affiliation(s)
| | | | - Davi Jorge Fontoura Solla
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Dr Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | - Iuri Santana Neville
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Dr Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | - Eberval Gadelha Figueiredo
- Department of Neurology, Division of Neurosurgery, Hospital das Clínicas da Faculdade de Medicina da Universidade de São Paulo, Rua Dr Ovídio Pires de Campos, 225 - Cerqueira César, São Paulo, SP, 05403-010, Brazil
| | - João Paulo Mota Telles
- Department of Neurology, University of São Paulo, Av Dr Arnaldo, 455 - Cerqueira César, São Paulo, SP, 01246-903, Brazil.
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Shen Y, Wen D, Liang Z, Wan L, Jiang Q, He H, He M. Brain tissue oxygen partial pressure monitoring and prognosis of patients with traumatic brain injury: a meta-analysis. Neurosurg Rev 2024; 47:222. [PMID: 38758384 PMCID: PMC11101534 DOI: 10.1007/s10143-024-02439-4] [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: 01/09/2024] [Revised: 03/20/2024] [Accepted: 04/27/2024] [Indexed: 05/18/2024]
Abstract
To assess whether monitoring brain tissue oxygen partial pressure (PbtO2) or employing intracranial pressure (ICP)/cerebral perfusion pressure (CCP)-guided management improves patient outcomes, including mortality, hospital length of stay (LOS), mean daily ICP and mean daily CCP during the intensive care unit(ICU)stay. We searched the Web of Science, EMBASE, PubMed, Cochrane Library, and MEDLINE databases until December 12, 2023. Prospective randomized controlled and cohort studies were included. A meta-analysis was performed for the primary outcome measure, mortality, following the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. Eleven studies with a total of 37,492 patients were included. The mortality in the group with PbtO2 was 29.0% (odds ratio: 0.73;95% confidence interval [CI]:0.56-0.96; P = 0.03; I = 55%), demonstrating a significant benefit. The overall hospital LOS was longer in the PbtO2 group than that in the ICP/CPP group (mean difference:2.03; 95% CI:1.03-3.02; P<0.0001; I = 39%). The mean daily ICP in the PbtO2 monitoring group was lower than that in the ICP/CPP group (mean difference:-1.93; 95% CI: -3.61 to -0.24; P = 0.03; I = 41%). Moreover, PbtO2 monitoring did not improve the mean daily CPP (mean difference:2.43; 95%CI: -1.39 to 6.25;P = 0.21; I = 56%).Compared with ICP/CPP monitoring, PbtO2 monitoring reduced the mortality and the mean daily ICP in patients with severe traumatic brain injury; however, no significant effect was noted on the mean daily CPP. In contrast, ICP/CPP monitoring alone was associated with a short hospital stay.
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Affiliation(s)
- Yuqi Shen
- Intensive Care Unit, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Dan Wen
- Intensive Care Unit, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Zhenghua Liang
- Intensive Care Unit, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Li Wan
- Intensive Care Unit, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Qingli Jiang
- Intensive Care Unit, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Haiyan He
- Intensive Care Unit, School of Medicine, Mianyang Central Hospital, University of Electronic Science and Technology of China, Mianyang, Sichuan Province, China
| | - Mei He
- Department of Nursing, School of Medicine, Mei He: RN, BSN, Mianyang Central Hospital, University of Electronic Science and Technology of China, No.12 Changjia Alley, Jingzhong Street, Fucheng District, Mianyang, 621000, Sichuan Province, China.
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Shanahan R, Avsar P, Watson C, Moore Z, Patton D, McEvoy NL, Curley G, O'Connor T. The impact of brain tissue oxygenation monitoring on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended in patients with moderate to severe traumatic brain injury: A systematic review. Nurs Crit Care 2023. [PMID: 37735107 DOI: 10.1111/nicc.12973] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/29/2022] [Revised: 08/09/2023] [Accepted: 08/11/2023] [Indexed: 09/23/2023]
Abstract
BACKGROUND Traumatic brain injuries (TBIs) are one of the leading causes of death or long-term disability around the world. As a result of improvements in supportive care, patients are surviving more severe insults with more pronounced dependency on their families, hospitals, and long-term care facilities. The introduction of brain tissue oxygenation (PbtO2) monitoring aims to recognize episodes of reduced cerebral perfusion with and without associated increased intracranial pressure (ICP). AIM The aim of this review is to determine the impact of PbtO2 on the Glasgow Outcome Scale/Glasgow Outcome Scale Extended (GOS/GOSE) in patients with moderate to severe TBI. DESIGN Systematic review with narrative and meta-analysis. All original research in which adult patients undergoing PbtO2 were compared with a control group of traditional ICP/cerebral perfusion pressure (CPP) monitoring. Both randomized controlled trials and observational studies were included in this review. METHODS Databases were searched in September 2022. The primary outcome of the review was the impact of PbtO2 monitoring on GOS/GOSE, while secondary outcomes were mortality and length of stay (LOS) in the intensive care unit (ICU). RESULTS Seven studies with a combined number of 770 patients were included in the review. These patients were adults ≥16 years of age. Only two of the studies included found a statistically significant association between PbtO2 monitoring and improved long-term neurological outcomes in patients with TBI (p = .01, p < .01). A meta-analysis of the secondary outcomes identified an associated reduction of mortality in favour of the group treated with PbtO2 monitoring (p < .0001). Results from studies examining LOS in ICU have demonstrated an associated increase of LOS in ICU in patients treated with PbtO2-guided therapy. CONCLUSION From the studies included in this review, only two found a statistically significant association between PbtO2 monitoring and long-term outcomes. It is unclear whether PbtO2 goal-directed therapy has a positive impact on the long-term neurological functions and mortality of patients suffering from TBI. A multicentre randomized controlled trial may provide further evidence, but not necessarily conclusive. RELEVANCE TO CLINICAL PRACTICE Further research is warranted to determine the efficacy of the introduction of this new monitoring system to guide local policy change.
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Affiliation(s)
- Ruth Shanahan
- Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
| | - Pinar Avsar
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Skin Wounds and Trauma (SWaT) Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
| | - Chanel Watson
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
| | - Zena Moore
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Skin Wounds and Trauma (SWaT) Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Nursing & Midwifery, Griffith University, Mount Gravatt, Queensland, Australia
- School of Health Sciences, Faculty of Life and Health Sciences Ulster University, UK
- Department of Public Health, Faculty of Medicine and Health Sciences, Ghent University, Gent, Belgium
- Lida Institute, Shanghai, China
- Cardiff University, Cardiff, UK
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
| | - Declan Patton
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Skin Wounds and Trauma (SWaT) Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Nursing & Midwifery, Griffith University, Mount Gravatt, Queensland, Australia
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
- Faculty of Science, Medicine and Health, University of Wollongong, Wollongong, New South Wales, Australia
| | - Natalie L McEvoy
- Department of Anaesthesia and Critical Care, RCSI, Dublin, Ireland
| | - Ger Curley
- Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, Beaumont Hospital, Dublin, Ireland
- Department of Anaesthesia and Critical Care, RCSI, Dublin, Ireland
| | - Tom O'Connor
- School of Nursing & Midwifery, Royal College of Surgeons in Ireland (RCSI) University of Medicine and Health Sciences, Dublin, Ireland
- Skin Wounds and Trauma (SWaT) Research Centre, RCSI University of Medicine and Health Sciences, Dublin, Ireland
- School of Nursing & Midwifery, Griffith University, Mount Gravatt, Queensland, Australia
- Lida Institute, Shanghai, China
- Fakeeh College of Health Sciences, Jeddah, Saudi Arabia
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Stein KY, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Zeiler FA. Intracranial Pressure Monitoring and Treatment Thresholds in Acute Neural Injury: A Narrative Review of the Historical Achievements, Current State, and Future Perspectives. Neurotrauma Rep 2023; 4:478-494. [PMID: 37636334 PMCID: PMC10457629 DOI: 10.1089/neur.2023.0031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 08/29/2023] Open
Abstract
Since its introduction in the 1960s, intracranial pressure (ICP) monitoring has become an indispensable tool in neurocritical care practice and a key component of the management of moderate/severe traumatic brain injury (TBI). The primary utility of ICP monitoring is to guide therapeutic interventions aimed at maintaining physiological ICP and preventing intracranial hypertension. The rationale for such ICP maintenance is to prevent secondary brain injury arising from brain herniation and inadequate cerebral blood flow. There exists a large body of evidence indicating that elevated ICP is associated with mortality and that aggressive ICP control protocols improve outcomes in severe TBI patients. Therefore, current management guidelines recommend a cerebral perfusion pressure (CPP) target range of 60-70 mm Hg and an ICP threshold of >20 or >22 mm Hg, beyond which therapeutic intervention should be initiated. Though our ability to achieve these thresholds has drastically improved over the past decades, there has been little to no change in the mortality and morbidity associated with moderate-severe TBI. This is a result of the "one treatment fits all" dogma of current guideline-based care that fails to take individual phenotype into account. The way forward in moderate-severe TBI care is through the development of continuously derived individualized ICP thresholds. This narrative review covers the topic of ICP monitoring in TBI care, including historical context/achievements, current monitoring technologies and indications, treatment methods, associations with patient outcome and multi-modal cerebral physiology, present controversies surrounding treatment thresholds, and future perspectives on personalized approaches to ICP-directed therapy.
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Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, Price Faculty of Engineering, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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Beynon C, Bernhard M, Brenner T, Dietrich M, Fiedler MO, Nusshag C, Weigand MA, Reuß CJ, Michalski D, Jungk C. [Focus neurosurgical intensive care medicine : Summary of selected intensive medical care studies]. DIE ANAESTHESIOLOGIE 2023:10.1007/s00101-023-01287-z. [PMID: 37195500 DOI: 10.1007/s00101-023-01287-z] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Subscribe] [Scholar Register] [Accepted: 04/04/2023] [Indexed: 05/18/2023]
Affiliation(s)
- Christopher Beynon
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Im Neuenheimer Feld 400, 69120, Heidelberg, Deutschland.
| | - Michael Bernhard
- Zentrale Notaufnahme, Universitätsklinikum Düsseldorf, Heinrich-Heine-Universität, Düsseldorf, Deutschland
| | - Thorsten Brenner
- Klinik für Anästhesiologie und Intensivmedizin, Universitätsklinikum Essen, Essen, Deutschland
| | - Maximilian Dietrich
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Mascha O Fiedler
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christian Nusshag
- Klinik für Endokrinologie, Stoffwechsel und klinische Chemie/Sektion Nephrologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Markus A Weigand
- Klinik für Anästhesiologie, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
| | - Christopher J Reuß
- Klinik für Anästhesiologie und operative Intensivmedizin, Klinikum Stuttgart, Stuttgart, Deutschland
| | - Dominik Michalski
- Klinik und Poliklinik für Neurologie, Universitätsklinikum Leipzig, Leipzig, Deutschland
| | - Christine Jungk
- Neurochirurgische Klinik, Universitätsklinikum Heidelberg, Heidelberg, Deutschland
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Vitt JR, Loper NE, Mainali S. Multimodal and autoregulation monitoring in the neurointensive care unit. Front Neurol 2023; 14:1155986. [PMID: 37153655 PMCID: PMC10157267 DOI: 10.3389/fneur.2023.1155986] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2023] [Accepted: 04/04/2023] [Indexed: 05/10/2023] Open
Abstract
Given the complexity of cerebral pathology in patients with acute brain injury, various neuromonitoring strategies have been developed to better appreciate physiologic relationships and potentially harmful derangements. There is ample evidence that bundling several neuromonitoring devices, termed "multimodal monitoring," is more beneficial compared to monitoring individual parameters as each may capture different and complementary aspects of cerebral physiology to provide a comprehensive picture that can help guide management. Furthermore, each modality has specific strengths and limitations that depend largely on spatiotemporal characteristics and complexity of the signal acquired. In this review we focus on the common clinical neuromonitoring techniques including intracranial pressure, brain tissue oxygenation, transcranial doppler and near-infrared spectroscopy with a focus on how each modality can also provide useful information about cerebral autoregulation capacity. Finally, we discuss the current evidence in using these modalities to support clinical decision making as well as potential insights into the future of advanced cerebral homeostatic assessments including neurovascular coupling.
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Affiliation(s)
- Jeffrey R. Vitt
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
- Department of Neurology, UC Davis Medical Center, Sacramento, CA, United States
| | - Nicholas E. Loper
- Department of Neurological Surgery, UC Davis Medical Center, Sacramento, CA, United States
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, United States
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Stein KY, Amenta F, Gomez A, Froese L, Sainbhi AS, Vakitbilir N, Marquez I, Zeiler FA. Associations between intracranial pressure thresholds and multimodal monitoring in acute traumatic neural injury: a scoping review. Acta Neurochir (Wien) 2023:10.1007/s00701-023-05587-6. [PMID: 37067617 DOI: 10.1007/s00701-023-05587-6] [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: 02/27/2023] [Accepted: 03/31/2023] [Indexed: 04/18/2023]
Abstract
BACKGROUND Current moderate/severe traumatic brain injury (TBI) guidelines suggest the use of an intracranial pressure (ICP) treatment threshold of 20 mmHg or 22 mmHg. Over the past decade, the use of various cerebral physiology monitoring devices has been incorporated into neurocritical care practice and termed "multimodal monitoring." Such modalities include those that monitor systemic hemodynamics, systemic and brain oxygenation, cerebral blood flow (CBF), cerebral autoregulation, electrophysiology, and cerebral metabolism. Given that the relationship between ICP and outcomes is not yet entirely understood, a comprehensive review of the literature on the associations between ICP thresholds and multimodal monitoring is still needed. METHODS We conducted a scoping review of the literature for studies that present an objective statistical association between ICP above/below threshold and any multimodal monitoring variable. MEDLINE, BIOSIS, Cochrane library, EMBASE, Global Health, and SCOPUS were searched from inception to July 2022 for relevant articles. Full-length, peer-reviewed, original works with a sample size of ≥50 moderate-severe TBI patients were included in this study. RESULTS A total of 13 articles were deemed eligible for final inclusion. The included articles were significantly heterogenous in terms of their designs, demographics, and results, making it difficult to draw any definitive conclusions. No literature describing the association between guideline-based ICP thresholds and measures of brain electrophysiology, cerebral metabolism, or direct metrics of CBF was found. CONCLUSION There is currently little literature that presents objective statistical associations between ICP thresholds and multimodal monitoring physiology. However, overall, the literature indicates that having ICP above guideline based thresholds is associated with increased blood pressure, increased cardiac decoupling, reduced parenchymal brain oxygen tension, and impaired cerebral autoregulation, with no association with CBF velocity within the therapeutic range of ICP. There was insufficient literature to comment on other multimodal monitoring measures.
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Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
| | - Fiorella Amenta
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Izabella Marquez
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Centre on Aging, University of Manitoba, Winnipeg, Canada
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Lang SS, Rahman R, Kumar N, Tucker A, Flanders TM, Kirschen M, Huh JW. Invasive Neuromonitoring Modalities in the Pediatric Population. Neurocrit Care 2023; 38:470-485. [PMID: 36890340 DOI: 10.1007/s12028-023-01684-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 01/30/2023] [Indexed: 03/10/2023]
Abstract
Invasive neuromonitoring has become an important part of pediatric neurocritical care, as neuromonitoring devices provide objective data that can guide patient management in real time. New modalities continue to emerge, allowing clinicians to integrate data that reflect different aspects of cerebral function to optimize patient management. Currently, available common invasive neuromonitoring devices that have been studied in the pediatric population include the intracranial pressure monitor, brain tissue oxygenation monitor, jugular venous oximetry, cerebral microdialysis, and thermal diffusion flowmetry. In this review, we describe these neuromonitoring technologies, including their mechanisms of function, indications for use, advantages and disadvantages, and efficacy, in pediatric neurocritical care settings with respect to patient outcomes.
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Affiliation(s)
- Shih-Shan Lang
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA. .,Department of Neurosurgery, Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA.
| | - Raphia Rahman
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA.,School of Osteopathic Medicine, Rowan University, Stratford, NJ, USA
| | - Nankee Kumar
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Alexander Tucker
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Tracy M Flanders
- Division of Neurosurgery, Children's Hospital of Philadelphia, 3401 Civic Center Boulevard, 6 Wood Center, Philadelphia, PA, 19104, USA
| | - Matthew Kirschen
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
| | - Jimmy W Huh
- Department of Anesthesiology and Critical Care Medicine, Children's Hospital of Philadelphia and Perelman School of Medicine, University of Pennsylvania, Philadelphia, PA, USA
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Rakkar J, Azar J, Pelletier JH, Au AK, Bell MJ, Simon DW, Kochanek PM, Clark RSB, Horvat CM. Temporal Patterns in Brain Tissue and Systemic Oxygenation Associated with Mortality After Severe Traumatic Brain Injury in Children. Neurocrit Care 2023; 38:71-84. [PMID: 36171518 PMCID: PMC9957965 DOI: 10.1007/s12028-022-01602-3] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Accepted: 08/30/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Brain tissue hypoxia is an independent risk factor for unfavorable outcomes in traumatic brain injury (TBI); however, systemic hyperoxemia encountered in the prevention and/or response to brain tissue hypoxia may also impact risk of mortality. We aimed to identify temporal patterns of partial pressure of oxygen in brain tissue (PbtO2), partial pressure of arterial oxygen (PaO2), and PbtO2/PaO2 ratio associated with mortality in children with severe TBI. METHODS Data were extracted from the electronic medical record of a quaternary care children's hospital with a level I trauma center for patients ≤ 18 years old with severe TBI and the presence of PbtO2 and/or intracranial pressure monitors. Temporal analyses were performed for the first 5 days of hospitalization by using locally estimated scatterplot smoothing for less than 1,000 observations and generalized additive models with integrated smoothness estimation for more than 1,000 observations. RESULTS A total of 138 intracranial pressure-monitored patients with TBI (median 5.0 [1.9-12.8] years; 65% boys; admission Glasgow Coma Scale score 4 [3-7]; mortality 18%), 71 with PbtO2 monitors and 67 without PbtO2 monitors were included. Distinct patterns in PbtO2, PaO2, and PbtO2/PaO2 were evident between survivors and nonsurvivors over the first 5 days of hospitalization. Time-series analyses showed lower PbtO2 values on day 1 and days 3-5 and lower PbtO2/PaO2 ratios on days 1, 2, and 5 among patients who died. Analysis of receiver operating characteristics curves using Youden's index identified a PbtO2 of 30 mm Hg and a PbtO2/PaO2 ratio of 0.12 as the cut points for discriminating between survivors and nonsurvivors. Univariate logistic regression identified PbtO2 < 30 mm Hg, hyperoxemia (PaO2 ≥ 300 mm Hg), and PbtO2/PaO2 ratio < 0.12 to be independently associated with mortality. CONCLUSIONS Lower PbtO2, higher PaO2, and lower PbtO2/PaO2 ratio, consistent with impaired oxygen diffusion into brain tissue, were associated with mortality in this cohort of children with severe TBI. These results corroborate our prior work that suggests targeting a higher PbtO2 threshold than recommended in current guidelines and highlight the potential use of the PbtO2/PaO2 ratio in the management of severe pediatric TBI.
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Affiliation(s)
- Jaskaran Rakkar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Justin Azar
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Pediatric Critical Care, Geisinger Medical Center, Danville, PA, USA
| | - Jonathan H Pelletier
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Alicia K Au
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Michael J Bell
- Division of Critical Care Medicine, Children's National Hospital, Washington, DC, USA
| | - Dennis W Simon
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Patrick M Kochanek
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Robert S B Clark
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA
| | - Christopher M Horvat
- Department of Critical Care Medicine, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Safar Center for Resuscitation Research, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Department of Pediatrics, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA.
- Brain Care Institute, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
- Department of Pediatrics, Division of Health Informatics, UPMC Children's Hospital of Pittsburgh, Pittsburgh, PA, USA.
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10
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Brain Tissue Oxygen Levels as a Perspective Therapeutic Target in Traumatic Brain Injury. Retrospective Cohort Study. J Crit Care Med (Targu Mures) 2023; 9:12-19. [PMID: 36890978 PMCID: PMC9987269 DOI: 10.2478/jccm-2023-0001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2022] [Accepted: 11/30/2022] [Indexed: 02/10/2023] Open
Abstract
Introduction Management of traumatic brain injury (TBI) requires a multidisciplinary approach and represents a significant challenge for both neurosurgeons and intensivists. The role of brain tissue oxygenation (PbtO2) monitoring and its impact on posttraumatic outcomes remains a controversial topic. Aim of the study Our study aimed to evaluate the impact of PbtO2 monitoring on mortality, 30 days and 6 months neurological outcomes in patients with severe TBI compared with those resulting from standard intracranial pressure (ICP) monitoring. Material and methods In this retrospective cohort study, we analysed the outcomes of 77 patients with severe TBI who met the inclusion criteria. These patients were divided into two groups, including 37 patients who were managed with ICP and PbtO2 monitoring protocols and 40 patients who were managed using ICP protocols alone. Results There were no significant differences in demographic data between the two groups. We found no statistically significant differences in mortality or Glasgow Outcome Scale (GOS) scores one month after TBI. However, our results revealed that GOS scores at 6 months had improved significantly among patients managed with PbtO2; this finding was particularly notable for Glasgow Outcome Scale (GOS) scores of 4-5. Close monitoring and management of reductions in PbtO2, particularly by increasing the fraction of inspired oxygen, was associated with higher partial pressures of oxygen in this group. Conclusions Monitoring of PbtO2 may facilitate the appropriate evaluation and treatment of low PbtO2 and represents a promising tool for the management of patients with severe TBI. Additional studies will be needed to confirm these findings.
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11
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Brain Oxygen-Directed Management of Aneurysmal Subarachnoid Hemorrhage. Temporal Patterns of Cerebral Ischemia During Acute Brain Attack, Early Brain Injury, and Territorial Sonographic Vasospasm. World Neurosurg 2022; 166:e215-e236. [PMID: 35803565 DOI: 10.1016/j.wneu.2022.06.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. METHODS This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40). RESULTS The brain oxygen-directed protocol reduced Lbo2 (Pbto2 [partial pressure of brain tissue oxygen] <20 mm Hg) from 67% to 15% during acute brain attack (<24 hours of ictus), by increasing Pbto2 from 11.31 ± 9.34 to 27.85 ± 6.76 (P < 0.0001) and then to 29.09 ± 17.88 within 72 hours. Day-after-bleed, Fio2 change, ICP, hemoglobin, and oxygen saturation were predictors for Pbto2 during early brain injury. Transcranial Doppler ultrasonography velocities (>20 cm/second) increased at day 2. During DCI caused by territorial sonographic vasospasm (TSV), middle cerebral artery mean velocity (Vm) increased from 45.00 ± 15.12 to 80.37 ± 38.33/second by day 4 with concomitant Pbto2 reduction from 29.09 ± 17.88 to 22.66 ± 8.19. Peak TSV (days 7-12) coincided with decline in Pbto2. Nicardipine mitigated Lbo2 during peak TSV, in contrast to nimodipine, with survival benefit (P < 0.01). Intravenous and cisternal nicardipine combination had survival benefit (Cramer Φ = 0.43 and 0.327; G2 = 28.32; P < 0.001). This study identifies 4 zones of Lbo2 during survival benefit (Cramer Φ = 0.43 and 0.3) TSV, uncompensated; global cerebral ischemia, compensated, and normal Pbto2. Admission Glasgow Coma Scale score (not increased ICP) was predictive of low Pbto2 (β = 0.812, R2 = 0.661, F1,30 = 58.41; P < 0.0001) during early brain injury. Coma was the only credible predictor for mortality (odds ratio, 7.33/>4.8∗; χ2 = 7.556; confidence interval, 1.70-31.54; P < 0.01) followed by basilar aneurysm, poor grade, high ICP and Lbo2 during TSV. Global cerebral ischemia occurs immediately after the ictus, persisting in 30% of patients despite the high therapeutic intensity level, superimposed by DCI during TSV. CONCLUSIONS We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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12
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The Impact of Invasive Brain Oxygen Pressure Guided Therapy on the Outcome of Patients with Traumatic Brain Injury: A Systematic Review and Meta-Analysis. Neurocrit Care 2022; 37:779-789. [PMID: 36180764 DOI: 10.1007/s12028-022-01613-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/10/2022] [Accepted: 09/16/2022] [Indexed: 11/25/2022]
Abstract
Traumatic brain injury (TBI) is a major public health burden, causing death and disability worldwide. Intracranial hypertension and brain hypoxia are the main mechanisms of secondary brain injury. As such, management strategies guided by intracranial pressure (ICP) and brain oxygen (PbtO2) monitoring could improve the prognosis of these patients. Our objective was to summarize the current evidence regarding the impact of PbtO2-guided therapy on the outcome of patients with TBI. We performed a systematic search of PubMed, Scopus, and the Cochrane library databases, following the protocol registered in PROSPERO. Only studies comparing PbtO2/ICP-guided therapy with ICP-guided therapy were selected. Primary outcome was neurological outcome at 3 and 6 months assessed by using the Glasgow Outcome Scale; secondary outcomes included hospital and long-term mortality, burden of intracranial hypertension, and brain tissue hypoxia. Out of 6254 retrieved studies, 15 studies (n = 37,245 patients, of who 2184 received PbtO2-guided therapy) were included in the final analysis. When compared with ICP-guided therapy, the use of combined PbO2/ICP-guided therapy was associated with a higher probability of favorable neurological outcome (odds ratio 2.21 [95% confidence interval 1.72-2.84]) and of hospital survival (odds ratio 1.15 [95% confidence interval 1.04-1.28]). The heterogeneity (I2) of the studies in each analysis was below 40%. However, the quality of evidence was overall low to moderate. In this meta-analysis, PbtO2-guided therapy was associated with reduced mortality and more favorable neurological outcome in patients with TBI. The low-quality evidence underlines the need for the results from ongoing phase III randomized trials.
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13
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Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome. Curr Treat Options Neurol 2022; 24:383-408. [PMID: 35965956 PMCID: PMC9363869 DOI: 10.1007/s11940-022-00726-3] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 06/15/2022] [Indexed: 12/15/2022]
Abstract
Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (PaO2) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.
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Barrit S, Al Barajraji M, El Hadweh S, Dewitte O, Torcida N, Andre J, Taccone FS, Schuind S, Gouvêa Bogossian E. Brain Tissue Oxygenation-Guided Therapy and Outcome in Traumatic Brain Injury: A Single-Center Matched Cohort Study. Brain Sci 2022; 12:brainsci12070887. [PMID: 35884694 PMCID: PMC9315682 DOI: 10.3390/brainsci12070887] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 06/30/2022] [Accepted: 07/05/2022] [Indexed: 12/10/2022] Open
Abstract
Brain tissue oxygenation (PbtO2)-guided therapy can improve the neurological outcome of traumatic brain injury (TBI) patients. With several Phase-III ongoing studies, most of the existing evidence is based on before-after cohort studies and a phase-II randomized trial. The aim of this study was to assess the effectiveness of PbtO2-guided therapy in a single-center cohort. We performed a retrospective analysis of consecutive severe TBI patients admitted to our center who received either intracranial pressure (ICP) guided therapy (from January 2012 to February 2016) or ICP/PbtO2-guided therapy (February 2017 to December 2019). A genetic matching was performed based on covariates including demographics, comorbidities, and severity scores on admission. Intracranial hypertension (IH) was defined as ICP > 20 mmHg for at least 5 min. Brain hypoxia (BH) was defined as PbtO2 < 20 mmHg for at least 10 min. IH and BH were targeted by specific interventions. Mann−Whitney U and Fisher’s exact tests were used to assess differences between groups. A total of 35 patients were matched in both groups: significant differences in the occurrence of IH (ICP 85.7% vs. ICP/PbtO2 45.7%, p < 0.01), ICU length of stay [6 (3−13) vs. 16 (9−25) days, p < 0.01] and Glasgow Coma Scale at ICU discharge [10 (5−14) vs. 13 (11−15), p = 0.036] were found. No significant differences in ICU mortality and Glasgow Outcome Scales at 3 months were observed. This study suggests that the role of ICP/PbtO2-guided therapy should await further confirmation in well-conducted large phase III studies.
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Affiliation(s)
- Sami Barrit
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (S.B.); (M.A.B.); (S.E.H.); (O.D.); (S.S.)
| | - Mejdeddine Al Barajraji
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (S.B.); (M.A.B.); (S.E.H.); (O.D.); (S.S.)
| | - Salim El Hadweh
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (S.B.); (M.A.B.); (S.E.H.); (O.D.); (S.S.)
| | - Olivier Dewitte
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (S.B.); (M.A.B.); (S.E.H.); (O.D.); (S.S.)
| | - Nathan Torcida
- Department of Neurology, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
| | - Joachim Andre
- Department of Radiology, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
| | - Sophie Schuind
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium; (S.B.); (M.A.B.); (S.E.H.); (O.D.); (S.S.)
| | - Elisa Gouvêa Bogossian
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
- Correspondence:
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15
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Pinggera D, Rhomberg P, Beer R, Thomé C, Petr O. Brain Tissue Damage Induced by Multimodal Neuromonitoring In Situ during MRI after Severe Traumatic Brain Injury: Incidence and Clinical Relevance. J Clin Med 2022; 11:jcm11113169. [PMID: 35683575 PMCID: PMC9181231 DOI: 10.3390/jcm11113169] [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: 04/13/2022] [Revised: 05/28/2022] [Accepted: 05/30/2022] [Indexed: 11/28/2022] Open
Abstract
Both neuromonitoring and early magnetic resonance imaging (MRI) provide crucial information for treatment management and prognosis in patients with severe traumatic brain injury (sTBI). So far, neuromonitoring in situ impedes the routine implementation of MRI due to safety concerns. We aimed to evaluate the brain tissue damage induced by inserted neuromonitoring devices and its clinical relevance. Nineteen patients with sTBI and being exposed to at least one MRI with neuromonitoring in situ and one follow-up MRI after neuromonitoring removal were analyzed. All MRIs were reviewed for specific tissue damage. Three females and sixteen males (aged 20–74 years, mean 42.8 years) with an initial median GCS of 5 (range 3–8) were analyzed. No lesion was observed in six patients (31.6%), whereas another six patients (31.6%) demonstrated a detectable probe trajectory. Probe-related tissue damage was visible in seven patients (36.8%) with the size of the lesion prone to further enlarge with increasing cumulative duration of MRI examinations. Upon interdisciplinary evaluation, the lesions were not considered clinically relevant. Neuromonitoring probes in situ during MRI examinations may cause local brain tissue damage, yet without any clinical implications if placed correctly. Therefore, indications must be strictly based on joint decision from all involved disciplines.
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Affiliation(s)
- Daniel Pinggera
- Department of Neurosurgery, Medical University Innsbruck, 6020 Innsbruck, Austria; (C.T.); (O.P.)
- Correspondence: ; Tel.: +43-512-504-27452
| | - Paul Rhomberg
- Department of Neuroradiology, Medical University Innsbruck, 6020 Innsbruck, Austria;
| | - Ronny Beer
- Department of Neurology, Medical University Innsbruck, 6020 Innsbruck, Austria;
| | - Claudius Thomé
- Department of Neurosurgery, Medical University Innsbruck, 6020 Innsbruck, Austria; (C.T.); (O.P.)
| | - Ondra Petr
- Department of Neurosurgery, Medical University Innsbruck, 6020 Innsbruck, Austria; (C.T.); (O.P.)
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16
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Hays LM, Udy A, Adamides AA, Anstey JR, Bailey M, Bellapart J, Byrne K, Cheng A, Jamie Cooper D, Drummond KJ, Haenggi M, Jakob SM, Higgins AM, Lewis PM, Hunn MK, McNamara R, Menon DK, Murray L, Reddi B, Trapani T, Vallance S, Young PJ, Diaz-Arrastia R, Shutter L, Murray PT, Curley GF, Nichol A. Effects of brain tissue oxygen (PbtO2) guided management on patient outcomes following severe traumatic brain injury: A systematic review and meta-analysis. J Clin Neurosci 2022; 99:349-358. [DOI: 10.1016/j.jocn.2022.03.017] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/11/2021] [Revised: 02/24/2022] [Accepted: 03/10/2022] [Indexed: 11/30/2022]
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Casault C, Couillard P, Kromm J, Rosenthal E, Kramer A, Brindley P. Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners. J Intensive Care Soc 2022; 23:191-202. [PMID: 35615230 PMCID: PMC9125434 DOI: 10.1177/1751143720980273] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 09/17/2023] Open
Abstract
Traumatic brain injury (TBI) is common and potentially devastating. Traditional examination-based patient monitoring following TBI may be inadequate for frontline clinicians to reduce secondary brain injury through individualized therapy. Multimodal neurologic monitoring (MMM) offers great potential for detecting early injury and improving outcomes. By assessing cerebral oxygenation, autoregulation and metabolism, clinicians may be able to understand neurophysiology during acute brain injury, and offer therapies better suited to each patient and each stage of injury. Hence, we offer this primer on brain tissue oxygen monitoring, pressure reactivity index monitoring and cerebral microdialysis. This narrative review serves as an introductory guide to the latest clinically-relevant evidence regarding key neuromonitoring techniques.
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Affiliation(s)
- Colin Casault
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
| | - Philippe Couillard
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Julie Kromm
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Eric Rosenthal
- Department of Critical Care
Medicine, University of Alberta, Edmonton, Canada
| | - Andreas Kramer
- Department of Critical Care
Medicine, University of Calgary, Calgary, Canada
- Department of Clinical
Neurosciences, University of Calgary, Calgary, Canada
| | - Peter Brindley
- Department of Neurology, Harvard
University, Boston, MA, USA
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18
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Herculano-Houzel S, Rothman DL. From a Demand-Based to a Supply-Limited Framework of Brain Metabolism. Front Integr Neurosci 2022; 16:818685. [PMID: 35431822 PMCID: PMC9012138 DOI: 10.3389/fnint.2022.818685] [Citation(s) in RCA: 7] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2021] [Accepted: 01/10/2022] [Indexed: 12/20/2022] Open
Abstract
What defines the rate of energy use by the brain, as well as per neurons of different sizes in different structures and animals, is one fundamental aspect of neuroscience for which much has been theorized, but very little data are available. The prevalent theories and models consider that energy supply from the vascular system to different brain regions is adjusted both dynamically and in the course of development and evolution to meet the demands of neuronal activity. In this perspective, we offer an alternative view: that regional rates of energy use might be mostly constrained by supply, given the properties of the brain capillary network, the highly stable rate of oxygen delivery to the whole brain under physiological conditions, and homeostatic constraints. We present evidence that these constraints, based on capillary density and tissue oxygen homeostasis, are similar between brain regions and mammalian species, suggesting they derive from fundamental biophysical limitations. The same constraints also determine the relationship between regional rates of brain oxygen supply and usage over the full physiological range of brain activity, from deep sleep to intense sensory stimulation, during which the apparent uncoupling of blood flow and oxygen use is still a predicted consequence of supply limitation. By carefully separating "energy cost" into energy supply and energy use, and doing away with the problematic concept of energetic "demands," our new framework should help shine a new light on the neurovascular bases of metabolic support of brain function and brain functional imaging. We speculate that the trade-offs between functional systems and even the limitation to a single attentional spot at a time might be consequences of a strongly supply-limited brain economy. We propose that a deeper understanding of brain energy supply constraints will provide a new evolutionary understanding of constraints on brain function due to energetics; offer new diagnostic insight to disturbances of brain metabolism; lead to clear, testable predictions on the scaling of brain metabolic cost and the evolution of brains of different sizes; and open new lines of investigation into the microvascular bases of progressive cognitive loss in normal aging as well as metabolic diseases.
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Affiliation(s)
- Suzana Herculano-Houzel
- Department of Psychology, Vanderbilt University, Nashville, TN, United States,Department of Biological Sciences, Vanderbilt University, Nashville, TN, United States,Vanderbilt Brain Institute, Vanderbilt University, Nashville, TN, United States,*Correspondence: Suzana Herculano-Houzel,
| | - Douglas L. Rothman
- Department of Radiology and Biomedical Imaging, Yale University, New Haven, CT, United States,Department of Biomedical Engineering, Yale University, New Haven, CT, United States,Magnetic Resonance Research Center, Yale University, New Haven, CT, United States
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19
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Jin Y, Yin Y, Li C, Liu H, Shi J. Non-Invasive Monitoring of Human Health by Photoacoustic Spectroscopy. SENSORS 2022; 22:s22031155. [PMID: 35161900 PMCID: PMC8839463 DOI: 10.3390/s22031155] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 12/24/2021] [Revised: 01/27/2022] [Accepted: 01/27/2022] [Indexed: 12/24/2022]
Abstract
For certain diseases, the continuous long-term monitoring of the physiological condition is crucial. Therefore, non-invasive monitoring methods have attracted widespread attention in health care. This review aims to discuss the non-invasive monitoring technologies for human health based on photoacoustic spectroscopy. First, the theoretical basis of photoacoustic spectroscopy and related devices are reported. Furthermore, this article introduces the monitoring methods for blood glucose, blood oxygen, lipid, and tumors, including differential continuous-wave photoacoustic spectroscopy, microscopic photoacoustic spectroscopy, mid-infrared photoacoustic detection, wavelength-modulated differential photoacoustic spectroscopy, and others. Finally, we present the limitations and prospects of photoacoustic spectroscopy.
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Affiliation(s)
- Yongyong Jin
- College of Automation, Hangzhou Dianzi University, Hangzhou 310018, Zhejiang, China;
- Zhejiang Lab, Hangzhou 311121, Zhejiang, China; (Y.Y.); (C.L.)
| | - Yonggang Yin
- Zhejiang Lab, Hangzhou 311121, Zhejiang, China; (Y.Y.); (C.L.)
| | - Chiye Li
- Zhejiang Lab, Hangzhou 311121, Zhejiang, China; (Y.Y.); (C.L.)
| | - Hongying Liu
- College of Automation, Hangzhou Dianzi University, Hangzhou 310018, Zhejiang, China;
- Correspondence: (H.L.); (J.S.)
| | - Junhui Shi
- Zhejiang Lab, Hangzhou 311121, Zhejiang, China; (Y.Y.); (C.L.)
- Correspondence: (H.L.); (J.S.)
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20
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Straub S, Stiegeler J, El-Sanosy E, Bendszus M, Ladd ME, Schneider TM. A novel gradient echo data based vein segmentation algorithm and its application for the detection of regional cerebral differences in venous susceptibility. Neuroimage 2022; 250:118931. [PMID: 35085764 DOI: 10.1016/j.neuroimage.2022.118931] [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: 10/11/2021] [Revised: 01/14/2022] [Accepted: 01/23/2022] [Indexed: 11/18/2022] Open
Abstract
Accurate segmentation of cerebral venous vasculature from gradient echo data is of central importance in several areas of neuroimaging such as for the susceptibility-based assessment of brain oxygenation or planning of electrode placement in deep brain stimulation. In this study, a vein segmentation algorithm for single- and multi-echo gradient echo data is proposed. First, susceptibility maps, true susceptibility-weighted images, and, in the multi-echo case, R2* maps were generated from the gradient echo data. These maps were filtered with an inverted Hamming filter to suppress background contrast as well as artifacts from field inhomogeneities at the brain boundaries. A shearlet-based scale-wise representation was generated to calculate a vesselness function and to generate segmentations based on local thresholding. The accuracy of the proposed algorithm was evaluated for different echo times and image resolutions using a manually generated reference segmentation and two vein segmentation algorithms (Frangi vesselness-based, recursive vesselness filter) as a reference with the Dice and Cohen's coefficients as well as the modified Hausdorff distance. The Frangi-based and recursive vesselness filter methods were significantly outperformed with regard to all error metrics. Applying the algorithm, susceptibility differences likely related to differences in blood oxygenation between superficial and deep venous territories could be demonstrated.
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Affiliation(s)
- Sina Straub
- Divison of Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Janis Stiegeler
- Divison of Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, University of Heidelberg, Heidelberg, Germany
| | - Edris El-Sanosy
- Divison of Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany
| | - Martin Bendszus
- Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany
| | - Mark E Ladd
- Divison of Medical Physics in Radiology, German Cancer Research Center (DKFZ), Heidelberg, Germany; Faculty of Physics and Astronomy, University of Heidelberg, Heidelberg, Germany; Faculty of Medicine, University of Heidelberg, Heidelberg, Germany
| | - Till M Schneider
- Department of Neuroradiology, University of Heidelberg, Im Neuenheimer Feld 400, Heidelberg 69120, Germany.
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21
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Washer LA, Abramo T, Hardgrave H, Harris ZL, Meredith M, Moore K, Dalabih A, Williams D, Jorgenson-Stough A, Crawley L. Assessing the Impact of 3% Hypertonic Saline Hyperosmolar Therapy on Intubated Children With Isolated Traumatic Brain Injury by Cerebral Oximetry in a Pediatric Emergency Setting. Pediatr Emerg Care 2021; 37:e791-e804. [PMID: 32106155 DOI: 10.1097/pec.0000000000001959] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Abstract
BACKGROUND Intubated pediatric patients with isolated traumatic brain injury (TBI) are a diagnostic challenge for early detection of altered cerebral physiology instigated by trauma-induced increased intracranial pressure (ICP) while preventing secondary neuronal damage (secondary insult detection) and assessing the effects of increased ICP therapeutic interventions (3% hypertonic saline [HTS]). Invasive brain tissue oxygen monitoring is guiding new intensive care unit TBI management but is not pediatric emergency department (PED) readily accessible. Objective measurements on pediatric isolated TBI-altered bihemispheric cerebral physiology and treatment effects of 3% HTS are currently lacking. Cerebral oximetry can assess increased ICP-induced abnormal bihemispheric cerebral physiology by measuring regional tissue oxygenation (rcSO2) and cerebral blood volume index (CBVI) and the mechanical cerebrospinal fluid removal effects on the increased ICP-induced abnormal bihemispheric cerebral physiology.In the PED intubated patients with isolated TBI, assessing the 3% HTS therapeutic response is solely by vital signs and limited clinical assessment skills. Objective measurements of the 3% HTS hyperosmolar effects on the PED isolated TBI patients' altered bihemispheric cerebral physiology are lacking. We believe that bihemispheric rcSO2 and CBVI could elucidate similar data on 3% HTS impact and influence in the intubated isolated TBI patients. OBJECTIVE This study aimed to analyze the effects of 3% HTS on bihemispheric rcSO2 and CBVI in intubated patients with isolated TBI. METHODS An observational, retrospective analysis of bihemispheric rcSO2 and CBVI readings in intubated pediatric patients with isolated TBI receiving 3% HTS infusions, was performed. RESULTS From 2010 to 2017, 207 intubated patients with isolated TBI received 3% HTS infusions (median age, 2.9 [1.1-6.9 years]; preintubation Glasgow Coma Scale score, 7 [6-8]). The results were as follows: initial pre-3% HTS, 43% (39.5% to 47.5%; left) and 38% (35% to 42%; right) for rcSO2 < 60%, and 8 (-28 to 21; left) and -15 (-34 to 22; right) for CBVI; post-3% HTS, 68.5% (59.3% to 76%, P < 0.0001; left) and 62.5% (56.0% to 74.8%, P < 0.0001; right) for rcSO2 < 60%, and 12 (-7 to 24, P = 0.04; left) and 14 (-21 to 22, P < 0.0001; right) for CBVI; initial pre-3% HTS, 90% (83% to 91%; left) and 87% (82% to 92%; right) for rcSO2 > 80%, and 16.5 (6 to 33, P < 0.0001; left) and 16.8 (-2.5 to 27.5, P = 0.005; right) for CBVI; and post-3% HTS, 69% (62% to 72.5%, P < 0.0001; left) and 63% (59% to 72%, P < 0.0001; right) for rcSO2 > 80%, and 16.5 (6 to 33, P < 0.0001; left) and 16.8 (-2.5 to 27.5, P = 0.005; right) for CBVI. The following results for cerebral pathology pre-3% HTS were as follows: epidural: 85% (58% to 88.5%) for left rcSO2 and -9.25 (-34 to 19) for left CBVI, and 85.5% (57.5% to 89%) for right rcSO2 and -12.5 (-21 to 27) for CBVI; subdural: 45% (38% to 54%) for left rcSO2 and -9.5 (-25 to 19) for left CBVI, and 40% (33% to 49%) for right rcSO2 and -15 (-30.5 to 5) for CBVI. The following results for cerebral pathology post-3% HTS were as follows: epidural: 66% (58% to 69%, P = 0.03) for left rcSO2 and 15 (-1 to 21, P = 0.0004) for left CBVI, and 63% (52% to 72%, P = 0.009) for right rcSO2, and 15.5 (-22 to 24, P = 0.02) for CBVI; subdural: 63% (56% to 72%, P < 0.0001) for left rcSO2 and 9 (-20 to 22, P < 0.0001) for left CBVI, and 62.5% (48% to 73%, P < 0.0001) for right rcSO2, and 3 (-26 to 22, P < 0.0001) for CBVI. Overall, heart rate showed no significant change. Three percent HTS effect on interhemispheric rcSO2 difference >10 showed rcSO2 < 60%, and subdural hematomas had the greatest reduction (P < 0.001). The greatest positive changes occurred in bihemispheric or one-hemispheric rcSO2 < 60% with an interhemispheric discordance rcSO2 > 10 and required the greatest number of 3% HTS infusions. For 3% HTS 15% rcSO2 change time effect, all patients achieved positive change with subdural hematomas and hemispheric rcSO2 readings <60% with the shortest achievement time of 1.2 minutes (0.59-1.75; P < 0.001). CONCLUSIONS In intubated pediatric patients with isolated TBI who received 3% HTS infusions, bihemispheric rcSO2 and CBVI readings immediately detected and trended the 3% HTS effects on the trauma-induced cerebral pathophysiology. The 3% HTS infusion produced a significant improvement in rcSO2 and CBVI readings and a reduction in interhemispheric rcSO2 discordance differences. In patients with bihemispheric or one-hemispheric rcSO2 readings <60% with or without an interhemispheric discordance, rcSO2 > 10 demonstrated the greatest significant positive delta change and required the greatest numbers of 3% HTS infusions. Overall, 3% HTS produced a significant positive 15% change within 2.1 minutes of infusion, whereas heart rate showed no significant change. During trauma neuroresuscitation, especially in intubated isolated TBI patients requiring 3% HTS, cerebral oximetry has shown its functionality as a rapid adjunct neurological, therapeutic assessment tool and should be considered in the initial emergency department pediatric trauma neurological assessment and neuroresuscitation regimen.
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Affiliation(s)
- Leigh-Ann Washer
- From the Department of Pediatrics, University of Arkansas for Medical Sciences
| | - Thomas Abramo
- From the Department of Pediatrics, University of Arkansas for Medical Sciences
| | | | - Zena Leah Harris
- Department of Pediatrics, Feinberg School of Medicine, Northwestern Medicine, Lurie Children's Hospital, Chicago, IL
| | - Mark Meredith
- Department of Pediatrics, University of Tennessee, LeBonheur Children's Hospital, Memphis, TN
| | - Katherine Moore
- University of Arkansas for Medical Sciences, Little Rock, AR
| | - Abudulah Dalabih
- From the Department of Pediatrics, University of Arkansas for Medical Sciences
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Madsen FA, Andreasen TH, Lindschou J, Gluud C, Møller K. Ketamine for critically ill patients with severe acute brain injury: Protocol for a systematic review with meta-analysis and Trial Sequential Analysis of randomised clinical trials. PLoS One 2021; 16:e0259899. [PMID: 34780543 PMCID: PMC8592463 DOI: 10.1371/journal.pone.0259899] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/28/2021] [Accepted: 10/28/2021] [Indexed: 11/19/2022] Open
Abstract
INTRODUCTION Intensive care for patients with severe acute brain injury aims both to treat the immediate consequences of the injury and to prevent and treat secondary brain injury to ensure a good functional outcome. Sedation may be used to facilitate mechanical ventilation, for treating agitation, and for controlling intracranial pressure. Ketamine is an N-methyl-D-aspartate receptor antagonist with sedative, analgesic, and potentially neuroprotective properties. We describe a protocol for a systematic review of randomised clinical trials assessing the beneficial and harmful effects of ketamine for patients with severe acute brain injury. METHODS AND ANALYSIS We will systematically search international databases for randomised clinical trials, including CENTRAL, MEDLINE, Embase, and trial registries. Two authors will independently review and select trials for inclusion, and extract data. We will compare ketamine by any regimen versus placebo, no intervention, or other sedatives or analgesics for patients with severe acute brain injury. The primary outcomes will be functional outcome at maximal follow up, quality of life, and serious adverse events. We will also assess secondary and exploratory outcomes. The extracted data will be analysed using Review Manager and Trials Sequential Analysis. Evidence certainty will be graded using GRADE. ETHICS AND DISSEMINATION The results of the systematic review will be disseminated through peer-reviewed publication. With the review, we hope to inform future randomised clinical trials and improve clinical practice. PROSPERO NO CRD42021210447.
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Affiliation(s)
- Frederik Andreas Madsen
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Trine Hjorslev Andreasen
- Department of Neurosurgery, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
| | - Jane Lindschou
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
| | - Christian Gluud
- Copenhagen Trial Unit, Centre for Clinical Intervention Research, The Capital Region, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Regional Health Research, Faculty of Health Sciences, University of Southern Denmark, Odense, Denmark
| | - Kirsten Møller
- Department of Neuroanaesthesiology, Neuroscience Centre, Copenhagen University Hospital—Rigshospitalet, Copenhagen, Denmark
- Department of Clinical Medicine, Faculty of Health and Medical Sciences, University of Copenhagen, Copenhagen, Denmark
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23
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Gouvea Bogossian E, Diaferia D, Ndieugnou Djangang N, Menozzi M, Vincent JL, Talamonti M, Dewitte O, Peluso L, Barrit S, Al Barajraji M, Andre J, Schuind S, Creteur J, Taccone FS. Brain tissue oxygenation guided therapy and outcome in non-traumatic subarachnoid hemorrhage. Sci Rep 2021; 11:16235. [PMID: 34376735 PMCID: PMC8355344 DOI: 10.1038/s41598-021-95602-6] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/10/2021] [Accepted: 07/27/2021] [Indexed: 02/08/2023] Open
Abstract
Brain hypoxia can occur after non-traumatic subarachnoid hemorrhage (SAH), even when levels of intracranial pressure (ICP) remain normal. Brain tissue oxygenation (PbtO2) can be measured as a part of a neurological multimodal neuromonitoring. Low PbtO2 has been associated with poor neurologic recovery. There is scarce data on the impact of PbtO2 guided-therapy on patients’ outcome. This single-center cohort study (June 2014–March 2020) included all patients admitted to the ICU after SAH who required multimodal monitoring. Patients with imminent brain death were excluded. Our primary goal was to assess the impact of PbtO2-guided therapy on neurological outcome. Secondary outcome included the association of brain hypoxia with outcome. Of the 163 patients that underwent ICP monitoring, 62 were monitored with PbtO2 and 54 (87%) had at least one episode of brain hypoxia. In patients that required treatment based on neuromonitoring strategies, PbtO2-guided therapy (OR 0.33 [CI 95% 0.12–0.89]) compared to ICP-guided therapy had a protective effect on neurological outcome at 6 months. In this cohort of SAH patients, PbtO2-guided therapy might be associated with improved long-term neurological outcome, only when compared to ICP-guided therapy.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Daniela Diaferia
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Narcisse Ndieugnou Djangang
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Menozzi
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jean-Louis Vincent
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marta Talamonti
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Olivier Dewitte
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sami Barrit
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mejdeddine Al Barajraji
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Joachim Andre
- Department of Radiology, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Sophie Schuind
- Department of Neurosurgery, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
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Asgari S, Robba C, Beqiri E, Donnelly J, Gupta A, Badenes R, Sekhon M, Hutchinson PJ, Pelosi P, Gupta A. Analysis of the Association Between Lung Function and Brain Tissue Oxygen Tension in Severe Traumatic Brain Injury. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:27-30. [PMID: 33839812 DOI: 10.1007/978-3-030-59436-7_6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
INTRODUCTION Low brain tissue oxygen tension (PbtO2) has been shown to be an independent factor associated with unfavourable outcomes in traumatic brain injury (TBI). Although PbtO2 provides clinicians with an understanding of ischaemic and non-ischaemic derangements of brain physiology, the value alone can be the result of several factors, including partial arterial oxygenation pressure (PaO2), haemoglobin levels (Hb) and cerebral perfusion pressure (CPP). METHODS This chapter presents a single-centre, retrospective cohort study of 70 adult patients with severe TBI who were admitted to the Neurocritical Care Unit (NCCU) at Addenbrooke's Hospital (Cambridge, UK) between October 2014 and December 2017. A total of 303 simultaneous measurements of different variables that included (but were not limited to) intracranial pressure (ICP), PaO2, PbtO2, CPP and the fraction of inspired oxygen (FiO2) were considered in this work. We conducted a correlation analysis between all of the variables. We also implemented a longitudinal data analysis of the PbtO2 and PaO2/FiO2 ratio (PF ratio). RESULTS There were strong and independent correlations between PbtO2 and the PF ratio, and between PbtO2 and PaO2, with adjusted p values of <0.001 for both correlations. After adjustment for ICP, age, sex and the Glasgow Coma Scale (GCS) score, a PF ≤ 330 was shown to be an independent risk factor for a compromised PbtO2 value of <20, with an adjusted odds ratio of 1.94 (95% confidence interval 1.12-3.34) and a p value of 0.02. CONCLUSION Brain and lung interactions in patients with TBI patients have complex interrelationships. Our results confirm the importance of employing lung-protective strategies to prevent brain hypoxia in patients with TBI.
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Affiliation(s)
- Shadnaz Asgari
- Biomedical Engineering Department, California State University, Long Beach, CA, USA.
| | - Chiara Robba
- Anesthesia and Intensive Care, San Martino Policlinico Hospital, Scientific Institutes of Hospitalization and Care (IRCCS) for Oncology and Neurosciences, Genoa, Italy
| | - Erta Beqiri
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Joseph Donnelly
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Amit Gupta
- Neurosciences Critical Care, University of Cambridge, Cambridge, UK
| | - Rafael Badenes
- Department of Anesthesiology, Hospital Clìnico Universitario, Valencia, Spain
| | - Mypinder Sekhon
- Division of Critical Care Medicine, University of British Columbia, Vancouver, BC, Canada
| | | | - Paolo Pelosi
- Department of Surgical Sciences and Integrated Diagnostics (DISC), University of Genoa, Genoa, Italy
| | - Arun Gupta
- Neurosciences Critical Care, University of Cambridge, Cambridge, UK
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Yuan J, Botchway BOA, Zhang Y, Wang X, Liu X. Combined bioscaffold with stem cells and exosomes can improve traumatic brain injury. Stem Cell Rev Rep 2021; 16:323-334. [PMID: 31808037 DOI: 10.1007/s12015-019-09927-x] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
The intricacy of the brain, along with the existence of blood brain barrier (BBB) does complicate the delivery of effective therapeutics through simple intravascular injection. Hence, an effective delivery mechanism of therapeutics in the event of either traumatic brain injury (TBI) or other brain injuries is needed. Stem cells can promote regeneration and repair injury. The usage of biomaterials and exosomes in transporting stem cells to target lesion sites has been suggested as a potential option. The combination of biomaterials with modified exosomes can help in transporting stem cells to injury sites, whiles also increasing their survival and promoting effective treatment. Herein, we review the current researches pertinent to biological scaffolds and exosomes in repairing TBI and present the current progress and new direction in the clinical setting. We begin with the role of bioscaffold in treating neuronal conditions, the effect of exosomes in injury, and conclude with the improvement of TBI via the employment of combined exosomes, bioscaffold and stem cells.
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Affiliation(s)
- Jiaying Yuan
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China
| | - Benson O A Botchway
- Institute of Neuroscience, Zhejiang University School of Medicine, Hangzhou, China
| | - Yong Zhang
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China
| | - Xizhi Wang
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China
| | - Xuehong Liu
- Department of Histology and Embryology, Medical College, Shaoxing University, 312000, Shaoxing, Zhejiang, China.
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Hoffman H, Abi-Aad K, Bunch KM, Beutler T, Otite FO, Chin LS. Outcomes associated with brain tissue oxygen monitoring in patients with severe traumatic brain injury undergoing intracranial pressure monitoring. J Neurosurg 2021; 135:1799-1806. [PMID: 34852324 DOI: 10.3171/2020.11.jns203739] [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] [Received: 10/12/2020] [Accepted: 11/10/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain tissue oxygen monitoring combined with intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (sTBI) may confer better outcomes than ICP monitoring alone. The authors sought to investigate this using a national database. METHODS The National Trauma Data Bank from 2013 to 2017 was queried to identify patients with sTBI who had an external ventricular drain or intraparenchymal ICP monitor placed. Patients were stratified according to the placement of an intraparenchymal brain tissue oxygen tension (PbtO2) monitor, and a 2:1 propensity score matching pair was used to compare outcomes in patients with and those without PbtO2 monitoring. Sensitivity analyses were performed using the entire cohort, and each model was adjusted for age, sex, Glasgow Coma Scale score, Injury Severity Score, presence of hypotension, insurance, race, and hospital teaching status. The primary outcome of interest was in-hospital mortality, and secondary outcomes included ICU length of stay (LOS) and overall LOS. RESULTS A total of 3421 patients with sTBI who underwent ICP monitoring were identified. Of these, 155 (4.5%) patients had a PbtO2 monitor placed. Among the propensity score-matched patients, mortality occurred in 35.4% of patients without oxygen monitoring and 23.4% of patients with oxygen monitoring (OR 0.53, 95% CI 0.33-0.85; p = 0.007). The unfavorable discharge rates were 56.3% and 47.4%, respectively, in patients with and those without oxygen monitoring (OR 1.41, 95% CI 0.87-2.30; p = 0.168). There was no difference in overall LOS, but patients with PbtO2 monitoring had a significantly longer ICU LOS and duration of mechanical ventilation. In the sensitivity analysis, PbtO2 monitoring was associated with decreased odds of mortality (OR 0.56, 95% CI 0.37-0.84) but higher odds of unfavorable discharge (OR 1.59, 95% CI 1.06-2.40). CONCLUSIONS When combined with ICP monitoring, PbtO2 monitoring was associated with lower inpatient mortality for patients with sTBI. This supports the findings of the recent Brain Oxygen Optimization in Severe Traumatic Brain Injury phase 2 (BOOST 2) trial and highlights the importance of the ongoing BOOST3 trial.
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Affiliation(s)
| | | | | | - Timothy Beutler
- Departments of1Neurosurgery.,3Neurology, State University of New York Upstate Medical University, Syracuse, New York
| | - Fadar O Otite
- 3Neurology, State University of New York Upstate Medical University, Syracuse, New York
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Lindner A, Rass V, Ianosi BA, Schiefecker AJ, Kofler M, Gaasch M, Addis A, Rhomberg P, Pfausler B, Beer R, Schmutzhard E, Thomé C, Helbok R. Individualized blood pressure targets in the postoperative care of patients with intracerebral hemorrhage. J Neurosurg 2021; 135:1656-1665. [PMID: 33836501 DOI: 10.3171/2020.9.jns201024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data. METHODS Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD-lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism. RESULTS The mean patient age was 60 (range 51-66) years and the median [IQR] initial ICH volume was 47 [29-60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120-130 mm Hg: adj OR 2.4, p = 0.002; 130-140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140-150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70-80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130-140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003). CONCLUSIONS These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.
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Affiliation(s)
- Anna Lindner
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Verena Rass
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Bogdan-Andrei Ianosi
- 1Neurological Intensive Care Unit, Department of Neurology, and
- 2Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria; and
| | | | - Mario Kofler
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Max Gaasch
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Alberto Addis
- 3School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | | | - Ronny Beer
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | | | | | - Raimund Helbok
- 1Neurological Intensive Care Unit, Department of Neurology, and
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Abstract
PURPOSE OF REVIEW Each year in the United States there are over 2.5 million visits to emergency departments for traumatic brain injury (TBI), 300,000 hospitalizations, and 50,000 deaths. TBI initiates a complex cascade of events which can lead to significant secondary brain damage. Great interest exists in directly measuring cerebral oxygen delivery and demand after TBI to prevent this secondary injury. Several invasive, catheter-based devices are now available which directly monitor the partial pressure of oxygen in brain tissue (PbtO2), yet significant equipoise exists regarding their clinical use in severe TBI. RECENT FINDINGS There are currently three ongoing multicenter randomized controlled trials studying the use of PbtO2 monitoring in severe TBI: BOOST-3, OXY-TC, and BONANZA. All three have similar inclusion/exclusion criteria, treatment protocols, and outcome measures. Despite mixed existing evidence, use of PbtO2 is already making its way into new TBI guidelines such as the recent Seattle International Brain Injury Consensus Conference. Analysis of high-fidelity data from multimodal monitoring, however, suggests that PbtO2 may only be one piece of the puzzle in severe TBI. SUMMARY While current evidence regarding the use of PbtO2 remains mixed, three ongoing clinical trials are expected to definitively answer the question of what role PbtO2 monitoring plays in severe TBI.
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Affiliation(s)
- Matthew R. Leach
- University of Pittsburgh, Department of Critical Care Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213
| | - Lori A. Shutter
- University of Pittsburgh, Department of Critical Care Medicine, 3550 Terrace Street, Scaife Hall, Suite 600, Pittsburgh, PA 15213
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Mismatch between Tissue Partial Oxygen Pressure and Near-Infrared Spectroscopy Neuromonitoring of Tissue Respiration in Acute Brain Trauma: The Rationale for Implementing a Multimodal Monitoring Strategy. Int J Mol Sci 2021; 22:ijms22031122. [PMID: 33498736 PMCID: PMC7865258 DOI: 10.3390/ijms22031122] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/20/2020] [Revised: 01/18/2021] [Accepted: 01/19/2021] [Indexed: 12/21/2022] Open
Abstract
The brain tissue partial oxygen pressure (PbtO2) and near-infrared spectroscopy (NIRS) neuromonitoring are frequently compared in the management of acute moderate and severe traumatic brain injury patients; however, the relationship between their respective output parameters flows from the complex pathogenesis of tissue respiration after brain trauma. NIRS neuromonitoring overcomes certain limitations related to the heterogeneity of the pathology across the brain that cannot be adequately addressed by local-sample invasive neuromonitoring (e.g., PbtO2 neuromonitoring, microdialysis), and it allows clinicians to assess parameters that cannot otherwise be scanned. The anatomical co-registration of an NIRS signal with axial imaging (e.g., computerized tomography scan) enhances the optical signal, which can be changed by the anatomy of the lesions and the significance of the radiological assessment. These arguments led us to conclude that rather than aiming to substitute PbtO2 with tissue saturation, multiple types of NIRS should be included via multimodal systemic- and neuro-monitoring, whose values then are incorporated into biosignatures linked to patient status and prognosis. Discussion on the abnormalities in tissue respiration due to brain trauma and how they affect the PbtO2 and NIRS neuromonitoring is given.
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Individualized Brain Tissue Oxygen-Monitoring Probe Placement Helps to Guide Therapy and Optimizes Outcome in Neurocritical Care. Neurocrit Care 2020; 35:197-209. [PMID: 33326065 PMCID: PMC8285328 DOI: 10.1007/s12028-020-01171-3] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2020] [Accepted: 12/01/2020] [Indexed: 12/04/2022]
Abstract
Background/Objective In order to monitor tissue oxygenation in patients with acute neurological disorders, probes for measurement of brain tissue oxygen tension (ptO2) are often placed non-specifically in a right frontal lobe location. To improve the value of ptO2 monitoring, placement of the probe into a specific area of interest is desirable. We present a technique using CT-guidance to place the ptO2 probe in a particular area of interest based on the individual patient’s pathology. Methods In this retrospective cohort study, we analyzed imaging and clinical data from all patients who underwent CT-guided ptO2 probe placement at our institution between October 2017 and April 2019. Primary endpoint was successful placement of the probe in a particular area of interest rated by two independent reviewers. Secondary outcomes were complications from probe insertion, clinical consequences from ptO2 measurements, clinical outcome according to the modified Rankin Scale (mRS) as well as development of ischemia on follow-up imaging. A historical control group was selected from patients who underwent conventional ptO2 probe placement between January 2010 and October 2017. Results Eleven patients had 16 CT-guided probes inserted. In 15 (93.75%) probes, both raters agreed on the correct placement in the area of interest. Each probe triggered on average 0.48 diagnostic or therapeutic adjustments per day. Only one infarction within the vascular territory of a probe was found on follow-up imaging. Eight out of eleven patients (72.73%) reached a good outcome (mRS ≤ 3). In comparison, conventionally placed probes triggered less diagnostic and therapeutic adjustment per day (p = 0.007). Outcome was worse in the control group (p = 0.024). Conclusion CT-guided probe insertion is a reliable and easy technique to place a ptO2 probe in a particular area of interest in patients with potentially reduced cerebral oxygen supply. By adjusting treatment aggressively according to this individualized monitoring data, clinical outcome may improve.
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Fiore M, Bogossian E, Creteur J, Oddo M, Taccone FS. Role of brain tissue oxygenation (PbtO 2) in the management of subarachnoid haemorrhage: a scoping review protocol. BMJ Open 2020; 10:e035521. [PMID: 32933956 PMCID: PMC7493101 DOI: 10.1136/bmjopen-2019-035521] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/06/2019] [Revised: 07/30/2020] [Accepted: 08/04/2020] [Indexed: 12/16/2022] Open
Abstract
INTRODUCTION In patients with subarachnoid haemorrhage (SAH), the initial brain oedema and increased blood volume can cause an increase in intracranial pressure (ICP) leading to impaired cerebral perfusion and tissue hypoxia. However, ICP monitoring may not be enough to detect tissue hypoxia, which can also occur in the absence of elevated ICP. Moreover, some patients will experience tissue hypoxia in a later phase after admission due to the occurrence of delayed cerebral ischaemia. Therefore, the measurement of brain oxygenation using invasive techniques has become of great interest. This scoping review seeks to examine the role of brain tissue oxygenation in the management of patients with SAH, mapping the existing literature to identify areas for future research. METHODS AND ANALYSIS This scoping review has been planned following the Joanna Briggs Institute recommendations and the Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The literature search will be performed using several databases: Medline, EMBASE, the Cochrane Central Register of Controlled Trials and Grey literature. The database searches are planned from the inception to May 2020. Two reviewers will independently screen titles and abstracts, followed by full-text screening of potentially relevant articles with a standardised data extraction. Articles eligible for the inclusion will be discussed with a third reviewer. ETHICS AND DISSEMINATION This paper does not require ethics approval. The results of our evaluation will be disseminated on author's web sites. Additional dissemination will occur through presentations at conferences, such as courses and science education conferences, regionally and nationally, and through articles published in peer-reviewed journals. SCOPING REVIEW REGISTRATION Open Science Framework Registration: https://doi.org/10.17605/OSF.IO/ZYJ7R.Trial registration numberClinicalTrials.gov Identifier: NCT03754114.
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Affiliation(s)
- Marco Fiore
- Department of Intensive Care, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
- Department of Women, Child and General and Specialized Surgery, Università degli Studi della Campania Luigi Vanvitelli, Napoli, Italy
| | - Elisa Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Jacques Creteur
- Department of Intensive Care, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
| | - Mauro Oddo
- Department of Intensive Care Medicine, University of Lausanne, Lausanne, Vaud, Switzerland
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Bruxelles, Bruxelles, Belgium
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Payen JF, Richard M, Francony G, Audibert G, Barbier EL, Bruder N, Dahyot-Fizelier C, Geeraerts T, Gergele L, Puybasset L, Vigue B, Skaare K, Bosson JL, Bouzat P. Comparison of strategies for monitoring and treating patients at the early phase of severe traumatic brain injury: the multicentre randomised controlled OXY-TC trial study protocol. BMJ Open 2020; 10:e040550. [PMID: 32820002 PMCID: PMC7443301 DOI: 10.1136/bmjopen-2020-040550] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/13/2022] Open
Abstract
INTRODUCTION Intracranial hypertension is considered as an independent risk factor of mortality and neurological disabilities after severe traumatic brain injury (TBI). However, clinical studies have demonstrated that episodes of brain ischaemia/hypoxia are common despite normalisation of intracranial pressure (ICP). This study assesses the impact on neurological outcome of guiding therapeutic strategies based on the monitoring of both brain tissue oxygenation pressure (PbtO2) and ICP during the first 5 days following severe TBI. METHODS AND ANALYSIS Multicentre, open-labelled, randomised controlled superiority trial with two parallel groups in 300 patients with severe TBI. Intracerebral monitoring must be in place within the first 16 hours post-trauma. Patients are randomly assigned to the ICP group or to the ICP + PbtO2 group. The ICP group is managed according to the international guidelines to maintain ICP≤20 mm Hg. The ICP + PbtO2 group is managed to maintain PbtO2 ≥20 mm Hg in addition to the conventional optimisation of ICP. The primary outcome measure is the neurological status at 6 months as assessed using the extended Glasgow Outcome Scale. Secondary outcome measures include quality-of-life assessment, mortality rate, therapeutic intensity and incidence of critical events during the first 5 days. Analysis will be performed according to the intention-to-treat principle and full statistical analysis plan developed prior to database freeze. ETHICS AND DISSEMINATION This study has been approved by the Institutional Review Board of Sud-Est V (14-CHUG-48) and from the National Agency for Medicines and Health Products Safety (Agence Nationale de Sécurité du Médicament et des produits de santé) (141 435B-31). Results will be presented at scientific meetings and published in peer-reviewed publications.The study was registered with ClinTrials NCT02754063 on 28 April 2016 (pre-results).
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Affiliation(s)
- Jean-Francois Payen
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Institut des Neurosciences, INSERM, U1216, Grenoble, France
| | - Marion Richard
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Institut des Neurosciences, INSERM, U1216, Grenoble, France
| | - Gilles Francony
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Institut des Neurosciences, INSERM, U1216, Grenoble, France
| | - Gérard Audibert
- Department of Anaesthesia and Intensive Care, Lorraine University, Nancy University Hospital, Nancy, France
| | - Emmanuel L Barbier
- Department of Anaesthesia and Intensive Care, Univ. Grenoble Alpes, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble Institut des Neurosciences, INSERM, U1216, Grenoble, France
| | - Nicolas Bruder
- Department of Anaesthesiology and Intensive Care, Aix-Marseille University, Assistance Publique - Hôpitaux de Marseille, Marseille, France
| | - Claire Dahyot-Fizelier
- Department of Anaesthesia and Intensive Care, Poitiers University Hospital and Poitiers Hospital, Pharmacology of antimicrobial agents, INSERM U1070, Poitiers, France
| | - Thomas Geeraerts
- Department of Anaesthesia and Intensive Care, Toulouse University Hospital and Toulouse 3-Paul Sabatier University, Toulouse, France
| | - Laurent Gergele
- Department of Intensive care, Ramsay Sante, Hopital Privé de la Loire, Saint-Etienne, France
| | - Louis Puybasset
- Department of Anaesthesia and Critical Care, Sorbonne University, GRC 29, AP-HP, DMU DREAM, Pitié-Salpêtrière Hospital, Paris, France
| | - Bernard Vigue
- Department of Anaesthesia and Intensive care, Centre Hospitalier Universitaire de Bicêtre, Assistance Publique - Hopitaux de Paris, Le Kremlin Bicêtre, France
| | - Kristina Skaare
- Department of Public Health, Univ. Grenoble Alpes, CHU Grenoble Alpes, Grenoble, France
| | - Jean Luc Bosson
- TIMC IMAG, Centre Hospitalier Universitaire Grenoble Alpes, Grenoble, France
| | - Pierre Bouzat
- Centre Hospitalier Universitaire de Grenoble, Grenoble, France
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Robba C, Asgari S, Gupta A, Badenes R, Sekhon M, Bequiri E, Hutchinson PJ, Pelosi P, Gupta A. Lung Injury Is a Predictor of Cerebral Hypoxia and Mortality in Traumatic Brain Injury. Front Neurol 2020; 11:771. [PMID: 32849225 PMCID: PMC7426476 DOI: 10.3389/fneur.2020.00771] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/16/2019] [Accepted: 06/23/2020] [Indexed: 12/19/2022] Open
Abstract
Background: A major contributor to unfavorable outcome after traumatic brain injury (TBI) is secondary brain injury. Low brain tissue oxygen tension (PbtO2) has shown to be an independent predictor of unfavorable outcome. Although PbtO2 provides clinicians with an understanding of the ischemic and non-ischemic derangements of brain physiology, its value does not take into consideration systemic oxygenation that can influence patients' outcomes. This study analyses brain and systemic oxygenation and a number of related indices in TBI patients: PbtO2, partial arterial oxygenation pressure (PaO2), PbtO2/PaO2, ratio of PbtO2 to fraction of inspired oxygen (FiO2), and PaO2/FiO2. The primary aim of this study was to identify independent risk factors for cerebral hypoxia. Secondary goal was to determine whether any of these indices are predictors of mortality outcome in TBI patients. Materials and Methods: A single-centre retrospective cohort study of 70 TBI patients admitted to the Neurocritical Care Unit (NCCU) at Cambridge University Hospital in 2014-2018 and undergoing advanced neuromonitoring including invasive PbtO2 was conducted. Three hundred and three simultaneous measurements of PbtO2, PaO2, PbtO2/PaO2, PbtO2/FiO2, PaO2/FiO2 were collected and mortality at discharge from NCCU was considered as outcome. Generalized estimating equations were used to analyse the longitudinal data. Results: Our results showed PbtO2 of 28 mmHg as threshold to define cerebral hypoxia. PaO2/FiO2 found to be a strong and independent risk factor for cerebral hypoxia when adjusting for confounding factor of intracranial pressure (ICP) with adjusted odds ratio of 1.78, 95% confidence interval of (1.10-2.87) and p-value = 0.019. With respect to TBI outcome, compromised values of PbtO2, PbtO2/PaO2, PbtO2/FiO2, and PaO2/FiO2 were all independent predictors of mortality while considered individually and adjusting for confounding factors of ICP, age, gender, and cerebral perfusion pressure (CPP). However, when considering all the compromised values together, only PaO2/FiO2 became an independent predictor of mortality with adjusted odds ratio of 3.47 (1.20-10.04) and p-value = 0.022. Conclusions: Brain and Lung interaction in TBI patients is a complex interrelationship. PaO2/FiO2 seems to be a major determinant of cerebral hypoxia and mortality. These results confirm the importance of employing ventilator strategies to prevent cerebral hypoxia and improve the outcome in TBI patients.
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Affiliation(s)
- Chiara Robba
- Anaesthesia and Intensive Care, San Martino Policlinico Hospital, IRCCS for Oncology and Neuroscience, Genoa, Italy
| | - Shadnaz Asgari
- Biomedical Engineering Department, California State University, Long Beach, CA, United States.,Computer Engineering and Computer Science Department, California State University, Long Beach, CA, United States
| | - Amit Gupta
- Emergency Department, Broomfield Hospital, Mid-Essex Hospital Trust, Essex, United Kingdom
| | - Rafael Badenes
- Department of Surgery, University of Valencia, Valencia, Spain
| | - Mypinder Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Erta Bequiri
- Department of Neurosurgery, Addenbrooke's Hospital, Hills University of Cambridge, Cambridge, United Kingdom.,Department of Physiology and Transplantation, Milan University, Milan, Italy
| | - Peter J Hutchinson
- Department of Neurosurgery, Addenbrooke's Hospital, Hills University of Cambridge, Cambridge, United Kingdom
| | - Paolo Pelosi
- Dipartimento di Scienze Chirurgiche e Diagnostiche Integrate, Università Degli Studi di Genova, Genoa, Italy
| | - Arun Gupta
- Neurocritical Care Unit, Addenbrooke's Hospital, Cambridge, United Kingdom
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Brain Tissue Oxygen Response as Indicator for Cerebral Lactate Levels in Aneurysmal Subarachnoid Hemorrhage Patients. J Neurosurg Anesthesiol 2020; 34:193-200. [PMID: 32701532 DOI: 10.1097/ana.0000000000000713] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/29/2020] [Accepted: 06/05/2020] [Indexed: 11/25/2022]
Abstract
BACKGROUND Early detection of cerebral ischemia and metabolic crisis is crucial in critically ill subarachnoid hemorrhage (SAH) patients. Variable increases in brain tissue oxygen tension (PbtO2) are observed when the fraction of inspired oxygen (FiO2) is increased to 1.0. The aim of this prospective study was to evaluate whether a 3-minute hyperoxic challenge can identify patients at risk for cerebral ischemia detected by cerebral microdialysis. METHODS Twenty consecutive severe SAH patients undergoing continuous cerebral PbtO2 and microdialysis monitoring were included. FiO2 was increased to 1.0 for 3 minutes (the FiO2 challenge) twice a day and PbtO2 responses during the FiO2 challenges were related to cerebral microdialysis-measures, ie, lactate, the lactate-pyruvate ratio, and glycerol. Multivariable linear and logistic regression models were created for each outcome parameter. RESULTS After predefined exclusions, 274 of 400 FiO2 challenges were included in the analysis. Lower absolute increases in PbtO2 ([INCREMENT]PbtO2) during FiO2 challenges were significantly associated with higher cerebral lactate concentration (P<0.001), and patients were at higher risk for ischemic lactate levels >4 mmol/L (odds ratio 0.947; P=0.04). Median (interquartile range) [INCREMENT]PbtO2 was 7.1 (4.6 to 12.17) mm Hg when cerebral lactate was >4 mmol/L and 10.2 (15.76 to 14.24) mm Hg at normal lactate values (≤4 mmol/L). Median [INCREMENT]PbtO2 was significantly lower during hypoxic than during hyperglycolytic lactate elevations (4.6 vs. 10.6 mm Hg, respectively; P<0.001). Lactate-pyruvate ratio and glycerol levels were mainly determined by baseline characteristics. CONCLUSIONS A 3-minute FiO2 challenge is an easy to perform and feasible bedside diagnostic tool in SAH patients. The absolute increase in PbtO2 during the FiO2 challenge might be a useful surrogate marker to estimate cerebral lactate concentrations and might be used to identify patients at risk for impending ischemia.
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Lueckel SN, Teno JM, Stephen AH, Benoit E, Kheirbek T, Adams CA, Cioffi WG, Thomas KS. Population of Patients With Traumatic Brain Injury in Skilled Nursing Facilities: A Decade of Change. J Head Trauma Rehabil 2020; 34:E39-E45. [PMID: 29863612 PMCID: PMC6274633 DOI: 10.1097/htr.0000000000000393] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
OBJECTIVE To describe the natural history of patients with traumatic brain injury (TBI) admitted to skilled nursing facilities (SNFs) following hospitalizations. SETTING Between 2005 and 2014. PARTICIPANTS Adults who had incident admissions to skilled nursing facilities (SNFs) with a diagnosis of TBI. DESIGN Retrospective review of the Minimum Data Set. MAIN MEASURES Main variables were cognitive and physical function, length of stay, presence of feeding tube, terminal condition, and dementia. RESULTS Incident admissions to SNFs increased annually from 17 247 patients to 20 787 from 2005 to 2014. The percentage of patients with activities of daily living score 23 or more decreased from 25% to 14% (P < .05). The overall percentage of patients with severe cognitive impairment decreased from 18% to 10% (P < .05). More patients had a diagnosis of dementia in 2014 compared with previous years (P < .05), and the presence of a terminal condition increased from 1% to 1.5% over the 10-year period (P < .05). The percentage of patients who stayed fewer than 30 days was noted to increase steadily over the 10 years, starting with 48% in 2005 and ending with 53% in 2013 (P < .05). CONCLUSION Understanding past trends in TBI admissions to SNFs is necessary to guide appropriate discharge and predict future demand, as well as inform SNF policy and practice necessary to care for this subgroup of patients.
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Affiliation(s)
- Stephanie N Lueckel
- Department of Surgery (Drs Lueckel, Stephen, Benoit, Kheirbek, and Cioffi), Rhode Island Hospital, Warren Alpert Medical School at Brown University, Providence, Rhode Island; Department of Medicine, Division of Gerontology and Geriatric Medicine at University of Washington, Seattle (Dr Teno); and School of Public Health at Brown University, Providence Veterans Affairs Medical Center, Rhode Island (Dr Thomas)
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Giammattei L, Starnoni D, Maduri R, Bernini A, Abed-Maillard S, Rocca A, Cossu G, Simonin A, Eckert P, Bloch J, Levivier M, Oddo M, Messerer M, Daniel RT. Implementation of cisternostomy as adjuvant to decompressive craniectomy for the management of severe brain trauma. Acta Neurochir (Wien) 2020; 162:469-479. [PMID: 32016585 PMCID: PMC7046565 DOI: 10.1007/s00701-020-04222-y] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/24/2019] [Accepted: 01/10/2020] [Indexed: 10/27/2022]
Abstract
OBJECTIVE To evaluate the value of an adjuvant cisternostomy (AC) to decompressive craniectomy (DC) for the management of patients with severe traumatic brain injury (sTBI). METHODS A single-center retrospective quality control analysis of a consecutive series of sTBI patients surgically treated with AC or DC alone between 2013 and 2018. A subgroup analysis, "primary procedure" and "secondary procedure", was also performed. We examined the impact of AC vs. DC on clinical outcome, including long-term (6 months) extended Glasgow outcome scale (GOS-E), the duration of postoperative ventilation, and intensive care unit (ICU) stay, mortality, Glasgow coma scale at discharge, and time to cranioplasty. We also evaluated and analyzed the impact of AC vs. DC on post-procedural intracranial pressure (ICP) and brain tissue oxygen (PbO2) values as well as the need for additional osmotherapy and CSF drainage. RESULTS Forty patients were examined, 22 patients in the DC group, and 18 in the AC group. Compared with DC alone, AC was associated with significant shorter duration of mechanical ventilation and ICU stay, as well as better Glasgow coma scale at discharge. Mortality rate was similar. At 6-month, the proportion of patients with favorable outcome (GOS-E ≥ 5) was higher in patients with AC vs. DC [10/18 patients (61%) vs. 7/20 (35%)]. The outcome difference was particularly relevant when AC was performed as primary procedure (61.5% vs. 18.2%; p = 0.04). Patients in the AC group also had significant lower average post-surgical ICP values, higher PbO2 values and required less osmotic treatments as compared with those treated with DC alone. CONCLUSION Our preliminary single-center retrospective data indicate that AC may be beneficial for the management of severe TBI and is associated with better clinical outcome. These promising results need further confirmation by larger multicenter clinical studies. The potential benefits of cisternostomy should not encourage its universal implementation across trauma care centers by surgeons that do not have the expertise and instrumentation necessary for cisternal microsurgery. Training in skull base and vascular surgery techniques for trauma care surgeons would avoid the potential complications associated with this delicate procedure.
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Patchana T, Wiginton J, Brazdzionis J, Ghanchi H, Zampella B, Toor H, Dorkoski R, Mannickarottu A, Wacker M, Sweiss R, Miulli DE. Increased Brain Tissue Oxygen Monitoring Threshold to Improve Hospital Course in Traumatic Brain Injury Patients. Cureus 2020; 12:e7115. [PMID: 32257661 PMCID: PMC7101240 DOI: 10.7759/cureus.7115] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
Introduction This article is a retrospective analysis of the neurosurgical census at our institution to determine an optimal threshold for brain tissue oxygenation (PbtO2). The use of brain tissue oxygen monitoring has been in place for approximately three decades but data suggesting optimal thresholds to improve outcomes have been lacking. Though there are multiple modalities to monitor cerebral oxygenation, the monitoring of brain tissue oxygen tension has been deemed the gold standard. Still, it is not clear exactly how reductions in PbtO2 should be treated or what appropriate thresholds to treat might be. The aim of our study was to determine if our threshold of 28 mmHg for a good functional outcome could be correlated to the Glasgow Coma Scale (GCS) and Glasgow Outcome Scale (GOS). Methods A retrospective analysis of the Arrowhead Regional Medical Center (ARMC) Neurosurgery Census was performed. Patients from 2017-2019 who had placement of Licox® cerebral oxygen monitoring sensors (Integra® Lifesciences, Plainsboro Township, New Jersey) were included in the analysis. Fifteen patients were consecutively identified, all of which presented with traumatic brain injury (TBI). Data on age, gender, days in the intensive care unit (ICU), days before discharge or end of medical care, admission GCS, hospital length of stay, GOS, maximum and minimum PbtO2 values for five days following insertion, minimum and maximum intracranial pressures (ICPs), and brain temperature were included for analysis. Patient data were separated into two groups; those with consistently higher PbtO2 scores (≥ 28 mmHg; n = 7) and those with inconsistent/lower PbtO2 scores (< 28 mmHg; n = 8). Standard student t-tests were used to find potential statistical differences between the groups (α = 0.05). Results There were seven patients in the consistently high PbtO2 category (≥ 28 mmHg) and eight patients in the inconsistent/low PbtO2 category (<28 mmHg). The average maximum and minimum PbtO2 for the group displaying worse outcomes (as defined by GCS/GOS) was 23.0 mmHg and 14 mmHg, respectively. Those with consistent Day 2 PbtO2 scores of ≥ 28 mmHg had significantly higher GCS scores at discharge/end of medical care (p < 0.05). Average GCS for the patient group with >28 mmHg PbtO2 averaged over Days 2-5 group was 11.4 (n=7). Average GCS for the <28 group was 7.0 (n=8). The GCS for the >28 group was 63% higher than found in the <28 group (p = 0.03). GOS scores were significantly higher in those with consistently higher PbtO2 (≥ 28) than those with lower PbtO2 scores (< 28). The averages were 3.5 in the higher PbtO2 group as compared to 2 in the lower PbtO2 group. Conclusion Along with ICP monitors and monitoring in the assessment of CPP, brain tissue oxygenation allows yet another metric by which to optimize treatment in TBI patients. At our institution, a PbtO2 level of ≥ 28 mmHg is targeted in order to facilitate a good functional outcome in TBI patients. Keeping patients at this level improves GCS and GOS at discharge/end of medical treatment.
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Affiliation(s)
- Tye Patchana
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Wiginton
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - James Brazdzionis
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Hammad Ghanchi
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Bailey Zampella
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Harjyot Toor
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Ryan Dorkoski
- Environmental and Plant Science, Ohio University, Athens, USA
| | | | - Margaret Wacker
- Neurosurgery, Arrowhead Regional Medical Center, Colton, USA
| | - Raed Sweiss
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
| | - Dan E Miulli
- Neurosurgery, Riverside University Health System Medical Center, Moreno Valley, USA
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Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos. Neurocirugia (Astur) 2020; 31:24-36. [DOI: 10.1016/j.neucir.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 01/20/2023]
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Bailey ZS, Cardiff K, Yang X, Gilsdorf J, Shear D, Rasmussen TE, Leung LY. The Effects of Balloon Occlusion of the Aorta on Cerebral Blood Flow, Intracranial Pressure, and Brain Tissue Oxygen Tension in a Rodent Model of Penetrating Ballistic-Like Brain Injury. Front Neurol 2019; 10:1309. [PMID: 31920932 PMCID: PMC6930175 DOI: 10.3389/fneur.2019.01309] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2019] [Accepted: 11/26/2019] [Indexed: 12/14/2022] Open
Abstract
Trauma is among the leading causes of death in the United States. Technological advancements have led to the development of resuscitative endovascular balloon occlusion of the aorta (REBOA) which offers a pre-hospital option to non-compressible hemorrhage control. Due to the prevalence of concomitant traumatic brain injury (TBI), an understanding of the effects of REBOA on cerebral physiology is critical. To further this understanding, we employed a rat model of penetrating ballistic-like brain injury (PBBI). PBBI produced an injury pattern within the right frontal cortex and striatum that replicates the pathology from a penetrating ballistic round. Aortic occlusion was initiated 30 min post-PBBI and maintained continuously (cAO) or intermittently (iAO) for 30 min. Continuous measurements of mean arterial pressure (MAP), intracranial pressure (ICP), cerebral blood flow (CBF), and brain tissue oxygen tension (PbtO2) were recorded during, and for 60 min following occlusion. PBBI increased ICP and decreased CBF and PbtO2. The arterial balloon catheter effectively occluded the descending aorta which augmented MAP in the carotid artery. Despite this, CBF levels were not changed by aortic occlusion. iAO caused sustained adverse effects to ICP and PbtO2 while cAO demonstrated no adverse effects on either. Temporary increases in PbtO2 were observed during occlusion, along with restoration of sham levels of ICP for the remainder of the recordings. These results suggest that iAO may lead to prolonged cerebral hypertension following PBBI. Following cAO, ICP, and PbtO2 levels were temporarily improved. This information warrants further investigation using TBI-polytrauma model and provides foundational knowledge surrounding the non-hemorrhage applications of REBOA including neurogenic shock and stroke.
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Affiliation(s)
- Zachary S Bailey
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Katherine Cardiff
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Xiaofang Yang
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Janice Gilsdorf
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Deborah Shear
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States
| | - Todd E Rasmussen
- Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
| | - Lai Yee Leung
- Brain Trauma Neuroprotection, Center for Military Psychiatry and Neuroscience, Walter Reed Army Institute of Research, Silver Spring, MD, United States.,Department of Surgery, Uniformed Services University of the Health Sciences, Bethesda, MD, United States
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Mader MM, Leidorf A, Hecker A, Heimann A, Mayr PSM, Kempski O, Alessandri B, Wöbker G. Evaluation of a New Multiparameter Brain Probe for Simultaneous Measurement of Brain Tissue Oxygenation, Cerebral Blood Flow, Intracranial Pressure, and Brain Temperature in a Porcine Model. Neurocrit Care 2019; 29:291-301. [PMID: 29949006 PMCID: PMC6208836 DOI: 10.1007/s12028-018-0541-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
Abstract
BACKGROUND A novel multiparameter brain sensor (MPBS) allows the simultaneous measurement of brain tissue oxygenation (ptiO2), cerebral blood flow (CBF), intracranial pressure (ICP), and brain temperature with a single catheter. This laboratory investigation evaluates the MPBS in an animal model in relation to established reference probes. METHODS The study group consisted of 17 juvenile male pigs. Four MPBS and four reference probes were implanted per pig and compared simultaneously. The measured parameters were challenged by standardized provocations such as hyperoxia, dobutamine, and norepinephrine application, hypercapnia and hypoxia in combination with and without a controlled cortical impact (CCI) injury. Mean values over 2 min were collected for predefined time points and were analyzed using Bland-Altman plots. RESULTS The protocol was successfully conducted in 15 pigs of which seven received CCI. ICP and ptiO2 were significantly influenced by the provocations. Subtraction of MPBS from reference values revealed a mean difference (limits of agreement) of 3.7 (- 20.5 to 27.9) mm Hg, - 2.9 (- 7.9 to 2.1) mm Hg, and 5.1 (- 134.7 to 145.0) % for ptiO2, ICP, and relative CBF, respectively. CONCLUSIONS The MPBS is a promising measurement tool for multiparameter neuromonitoring. The conducted study demonstrates the in vivo functionality of the probe. Comparison with standard probes revealed a deviation which is mostly analogous to other multiparameter devices. However, further evaluation of the device is necessary before it can reliably be used for clinical decision making.
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Affiliation(s)
- Marius M Mader
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany.,Department of Neurosurgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Anna Leidorf
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Andreas Hecker
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Axel Heimann
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Petra S M Mayr
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Oliver Kempski
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany
| | - Beat Alessandri
- Institute for Neurosurgical Pathophysiology, University Medical Center of the Johannes Gutenberg-University, Langenbeckstr. 1, 55131, Mainz, Germany.
| | - Gabriele Wöbker
- HELIOS Universitätsklinikum Wuppertal, University Witten/Herdecke, 42283 , Wuppertal, Germany
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Idris Z, Song Yee A, Kandasamy R, Abd Manaf A, Hasyizan Bin Hassan M, Nazaruddin Wan Hassan W. Direct Brain Cooling in Treating Severe Traumatic Head Injury. TRAUMATIC BRAIN INJURY - NEUROBIOLOGY, DIAGNOSIS AND TREATMENT 2019. [DOI: 10.5772/intechopen.84685] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 09/02/2023]
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Intracranial Monitoring in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.008] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
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43
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Correlation between Glasgow coma scale and Jugular venous oxygen saturation in severe traumatic brain injury. EGYPTIAN JOURNAL OF ANAESTHESIA 2019. [DOI: 10.1016/j.egja.2013.02.008] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/21/2022] Open
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Vidya Shankar R, Kodibagkar VD. A faster PISTOL for 1 H MR-based quantitative tissue oximetry. NMR IN BIOMEDICINE 2019; 32:e4076. [PMID: 30811753 DOI: 10.1002/nbm.4076] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/19/2018] [Revised: 11/23/2018] [Accepted: 01/07/2019] [Indexed: 06/09/2023]
Abstract
Quantitative mapping of oxygen tension (pO2 ), noninvasively, could potentially be beneficial in cancer and stroke therapy for monitoring therapy and predicting response to certain therapies. Intracellular pO2 measurements may also prove useful in tracking the health of labeled cells and understanding the dynamics of cell therapy in vivo. Proton Imaging of Siloxanes to map Tissue Oxygenation Levels (PISTOL) is a relatively new oximetry technique that measures the T1 of administered siloxanes such as hexamethyldisiloxane (HMDSO), to map the tissue pO2 at various locations with a temporal resolution of 3.5 minutes. We have now developed a siloxane-selective Look-Locker imaging sequence equipped with an echo planar imaging (EPI) readout to accelerate PISTOL acquisitions. The new tissue oximetry sequence, referred to as PISTOL-LL, enables the mapping of HMDSO T1 , and hence tissue pO2 in under one minute. PISTOL-LL was tested and compared with PISTOL in vitro and in vivo. Both sequences were used to record dynamic changes in pO2 of the rat thigh muscle (healthy Fischer rats, n = 6), and showed similar results (P > 0.05) as the other, with each sequence reporting a significant increase in pO2 (P < 0.05) under hyperoxia compared with steady state normoxia. This study demonstrates the ability of the new sequence in rapidly and accurately mapping the pO2 changes and accelerating quantitative 1 H MR tissue oximetry by approximately 4-fold. The faster PISTOL-LL technique could enable dynamic 1 H oximetry with higher temporal resolution for assesing tissue oxygentation and tracking the health of transplanted cells labeled with siloxane-based probes. With minor modifications, this sequence can be useful for 19 F applications as well.
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Affiliation(s)
- Rohini Vidya Shankar
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
| | - Vikram D Kodibagkar
- School of Biological and Health Systems Engineering, Arizona State University, Tempe, AZ, USA
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Jacob M, Kale MN, Hasnain S. Correlation between cerebral co-oximetry (rSO2) and outcomes in traumatic brain injury cases: A prospective, observational study. Med J Armed Forces India 2019; 75:190-196. [PMID: 31065189 DOI: 10.1016/j.mjafi.2018.08.007] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/27/2017] [Accepted: 08/09/2018] [Indexed: 10/27/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI) is known to be an important reason for the increase in disabilities and deaths worldwide. Studies have demonstrated that brain tissue oxygen (PO2) monitoring reduces mortality significantly but is a invasive method of monitoring. Therefore, there is a need to monitor cerebral ischemia in TBI by noninvasive methods. The study aims to correlate cerebral co-oximetry and possible outcomes in patients with TBI. METHODS The study included 78 patients with TBI admitted in intensive care unit (ICU) with glascow coma scale (GCS) of 8 or less than 8. Near-infrared spectroscopy monitor is applied to the patients immediately after admission to ICU; readings are noted every 4 hours up to first 48 hours, and outcomes studied as survival or neurological deficit are noted at 28 days. RESULTS A total of 12 (15.4%) deaths were seen in this study. Survived patients were further divided into good recovery 33 (42.3%), moderate disability 21(26.9%), major disability 8 (10.3%), and persistent vegetative state 4 (5.1%). The rSO2 values in surviving patients were ranging from mean of 60.74% (standard deviation [SD] 4.38) to a mean of 64.98% (SD 5.01), and the mean rSO2 values in patients who died were ranging from a mean of 52.17% (SD 4.11) to a mean of 37.17% (SD 12.48). Lower rSO2 values were correlating significantly with worse neurological outcome or death by using two independent sample t-test (p < 0.001). CONCLUSION Cerebral co-oximetry is a simple noninvasive method for predicting the outcomes in TBI and can be used to guide the management of these patients.
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Affiliation(s)
- Mathews Jacob
- Brig i/c Adm, (Military Hospital Cardio Thoracic Centre), Pune 411040, India
| | - M N Kale
- Graded Specialist (Anaesthesiology), 162 Military Hospital, C/o 99 APO, India
| | - Shahabaz Hasnain
- Deputy Commandant, Command Hospital (Eastern Command), Kolkata, India
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46
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Stocker RA. Intensive Care in Traumatic Brain Injury Including Multi-Modal Monitoring and Neuroprotection. Med Sci (Basel) 2019; 7:medsci7030037. [PMID: 30813644 PMCID: PMC6473302 DOI: 10.3390/medsci7030037] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2018] [Revised: 02/01/2019] [Accepted: 02/14/2019] [Indexed: 12/20/2022] Open
Abstract
Moderate to severe traumatic brain injuries (TBI) require treatment in an intensive care unit (ICU) in close collaboration of a multidisciplinary team consisting of different medical specialists such as intensivists, neurosurgeons, neurologists, as well as ICU nurses, physiotherapists, and ergo-/logotherapists. Major goals include all measurements to prevent secondary brain injury due to secondary brain insults and to optimize frame conditions for recovery and early rehabilitation. The distinction between moderate and severe is frequently done based on the Glascow Coma Scale and therefore often is just a snapshot at the early time of assessment. Due to its pathophysiological pathways, an initially as moderate classified TBI may need the same sophisticated surveillance, monitoring, and treatment as a severe form or might even progress to a severe and difficult to treat affection. As traumatic brain injury is rather a syndrome comprising a range of different affections to the brain and as, e.g., age-related comorbidities and treatments additionally may have a great impact, individual and tailored treatment approaches based on monitoring and findings in imaging and respecting pre-injury comorbidities and their therapies are warranted.
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Affiliation(s)
- Reto A Stocker
- Institute for Anesthesiology and Intensive Care Medicine, Klinik Hirslanden, CH-8032 Zurich, Switzerland.
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47
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Bellapart J, Cuthbertson K, Dunster K, Diab S, Platts DG, Raffel C, Gabrielian L, Barnett A, Paratz J, Boots R, Fraser JF. The effects of normovolemic anemia and blood transfusion on cerebral microcirculation after severe head injury. Intensive Care Med Exp 2018; 6:46. [PMID: 30411308 PMCID: PMC6223395 DOI: 10.1186/s40635-018-0210-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/23/2018] [Accepted: 10/18/2018] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Cerebral regional microcirculation is altered following severe head injury. In addition to tissue disruption, partial pressure of tissue oxygenation is impaired due to an increase in the oxygen tissue gradient. The heterogenic distribution of cerebral microcirculation is multifactorial, and acute anemia challenges further the delivery of oxygen to tissues. Currently, a restrictive transfusion threshold is globally applied; however, it is unclear how anemia modifies regional cerebral microcirculation; hence, it is unclear if by aiming to a global endpoint, specific anatomical regions undergo ischemia. This study aims to quantify the temporal changes in cerebral microcirculation after severe head injury, under the effect of anemia and transfusion. It also aims to assess its effects specifically at the ischemic penumbra compared to contralateral regions and its interactions with axonal integrity in real time. Twelve ovine models were subjected to a severe contusion and acceleration-deceleration injury. Normovolemic anemia to a restrictive threshold was maintained after injury, followed by autologous transfusion. Direct quantification of cerebral microcirculation used cytometric count of color-coded microspheres. Axonal injury was assessed using amyloid precursor protein staining. RESULTS A mixed-effect regression model from pre-transfusion to post-transfusion times with a random intercept for each sheep was used. Cerebral microcirculation amongst subjects with normal intracranial pressure was maintained from baseline and increased further after transfusion. Subjects with high intracranial pressure had a consistent reduction of their microcirculation to ischemic thresholds (20-30 ml/100 g/min) without an improvement after transfusion. Cerebral PtiO2 was reduced when exposed to anemia but increased in a 9.6-fold with transfusion 95% CI 5.6 to 13.6 (p value < 0.001). CONCLUSIONS After severe head injury, the exposure to normovolemic anemia to a restrictive transfusion threshold, leads to a consistent reduction on cerebral microcirculation below ischemic thresholds, independent of cerebral perfusion pressure. Amongst subjects with raised intracranial pressure, microcirculation does not improve after transfusion. Cerebral oxymetry is impaired during anemia with a statistically significant increase after transfusion. Current transfusion practices in neurocritical care are based on a rigid hemoglobin threshold, a view that excludes cerebral metabolic demands and specific needs. An RCT exploring these concepts is warranted.
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Affiliation(s)
- Judith Bellapart
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia. .,Intensive Care Department, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4025, Australia.
| | - Kylie Cuthbertson
- Histopathology Department, Royal Brisbane and Women's Hospital, Herston, QLD, 4025, Australia
| | - Kimble Dunster
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Medical Engineering Research Facility, Queensland University of Technology, Stafford Heights, QLD, 4053, Australia
| | - Sara Diab
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Medical Engineering Research Facility, Queensland University of Technology, Stafford Heights, QLD, 4053, Australia
| | - David G Platts
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Department of Cardiology, The Prince Charles Hospital, Chermside, QLD, 4032, Australia
| | - Christopher Raffel
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Department of Cardiology, The Prince Charles Hospital, Chermside, QLD, 4032, Australia
| | - Levon Gabrielian
- Medical School Research Centre, Frome road, Adelaide, SA, 5005, Australia
| | - Adrian Barnett
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Institute of Health and Biomedical Innovation and School of Public Health and Social Work, Queensland University of Technology, 60 Musk Avenue, Kelvin Grove, QLD, 4059, Australia
| | - Jennifer Paratz
- School of Medicine, University of Queensland, Brisbane, Queensland, 4025, Australia.,Griffith University, Parkland Drive, Southport, 4215, Australia
| | - Rob Boots
- Intensive Care Department, Royal Brisbane and Women's Hospital, Butterfield Street, Herston, QLD, 4025, Australia
| | - John F Fraser
- Critical Care Research Group, University of Queensland, Brisbane, Queensland, Australia.,Intensive Care Department, The Prince Charles Hospital, Rode road, Chermside, QLD, 4032, Australia
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48
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Dellazizzo L, Demers SP, Charbonney E, Williams V, Serri K, Albert M, Giguère JF, Laroche M, Williamson D, Bernard F. Minimal PaO2 threshold after traumatic brain injury and clinical utility of a novel brain oxygenation ratio. J Neurosurg 2018; 131:1639-1647. [PMID: 30485198 DOI: 10.3171/2018.5.jns18651] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/07/2018] [Accepted: 05/16/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Avoiding decreases in brain tissue oxygenation (PbtO2) after traumatic brain injury (TBI) is important. How best to adjust PbtO2 remains unclear. The authors investigated the association between partial pressure of oxygen (PaO2) and PbtO2 to determine the minimal PaO2 required to maintain PbtO2 above the hypoxic threshold (> 20 mm Hg), accounting for other determinants of PbtO2 and repeated measurements in the same patient. They also explored the clinical utility of a novel concept, the brain oxygenation ratio (BOx ratio = PbtO2/PaO2) to detect overtreatment with the fraction of inspired oxygen (FiO2). METHODS A retrospective cohort study at an academic level 1 trauma center included 38 TBI patients who required the insertion of a monitor to measure PbtO2. Various determinants of PbtO2 were collected simultaneously whenever a routine arterial blood gas was drawn. A PbtO2/PaO2 ratio was calculated for each blood gas and plotted over time for each patient. All patients were managed according to a standardized clinical protocol. A mixed effects model was used to account for repeated measurements in the same patient. RESULTS A total of 1006 data points were collected. The lowest mean PaO2 observed to maintain PbtO2 above the ischemic threshold was 94 mm Hg. Only PaO2 and cerebral perfusion pressure were predictive of PbtO2 in multivariate analysis. The PbtO2/PaO2 ratio was below 0.15 in 41.7% of all measures and normal PbtO2 values present despite an abnormal ratio in 27.1% of measurements. CONCLUSIONS The authors' results suggest that the minimal PaO2 target to ensure adequate cerebral oxygenation during the first few days after TBI should be higher than that suggested in the Brain Trauma Foundation guidelines. The use of a PbtO2/PaO2 ratio (BOx ratio) may be clinically useful and identifies abnormal O2 delivery mechanisms (cerebral blood flow, diffusion, and cerebral metabolic rate of oxygen) despite normal PbtO2.
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Affiliation(s)
- Laura Dellazizzo
- Departments of1Neurosciences
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Simon-Pierre Demers
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Emmanuel Charbonney
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Virginie Williams
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Karim Serri
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Martin Albert
- 2Medicine
- 3Neurosurgery, and
- 4Pharmacy, Université de Montréal; and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Jean-François Giguère
- 3Neurosurgery, and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Mathieu Laroche
- 3Neurosurgery, and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - David Williamson
- 3Neurosurgery, and
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
| | - Francis Bernard
- 2Medicine
- 5Department of Critical Care, Centre intégré universitaire de santé et de services sociaux (CIUSSS) du Nord-de-l'Ile-de-Montréal, Hôpital du Sacré-Cœur de Montréal, Québec, Canada
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Davies DJ, Clancy M, Dehghani H, Lucas SJE, Forcione M, Yakoub KM, Belli A. Cerebral Oxygenation in Traumatic Brain Injury: Can a Non-Invasive Frequency Domain Near-Infrared Spectroscopy Device Detect Changes in Brain Tissue Oxygen Tension as Well as the Established Invasive Monitor? J Neurotrauma 2018; 36:1175-1183. [PMID: 29877139 DOI: 10.1089/neu.2018.5667] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
The cost and highly invasive nature of brain monitoring modality in traumatic brain injury patients currently restrict its utility to specialist neurological intensive care settings. We aim to test the abilities of a frequency domain near-infrared spectroscopy (FD-NIRS) device in predicting changes in invasively measured brain tissue oxygen tension. Individuals admitted to a United Kingdom specialist major trauma center were contemporaneously monitored with an FD-NIRS device and invasively measured brain tissue oxygen tension probe. Area under the curve receiver operating characteristic (AUROC) statistical analysis was utilized to assess the predictive power of FD-NIRS in detecting both moderate and severe hypoxia (20 and 10 mm Hg, respectively) as measured invasively. Sixteen individuals were prospectively recruited to the investigation. Severe hypoxic episodes were detected in nine of these individuals, with the NIRS demonstrating a broad range of predictive abilities (AUROC 0.68-0.88) from relatively poor to good. Moderate hypoxic episodes were detected in seven individuals with similar predictive performance (AUROC 0.576-0.905). A variable performance in the predictive powers of this FD-NIRS device to detect changes in brain tissue oxygen was demonstrated. Consequently, this enhanced NIRS technology has not demonstrated sufficient ability to replace the established invasive measurement.
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Affiliation(s)
- David James Davies
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Michael Clancy
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Hamid Dehghani
- 2 School of Computer Science, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Samuel John Edwin Lucas
- 3 School of Sport, Exercise and Rehabilitation Sciences, University of Birmingham, Birmingham, United Kingdom
| | - Mario Forcione
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Kamal Makram Yakoub
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
| | - Antonio Belli
- 1 National Institute for Health Research Surgical Reconstruction and Microbiology Research Centre, University Hospitals Birmingham NHS Foundation Trust, Birmingham, United Kingdom
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50
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Hirschi R, Hawryluk GWJ, Nielson JL, Huie JR, Zimmermann LL, Saigal R, Ding Q, Ferguson AR, Manley G. Analysis of high-frequency PbtO2 measures in traumatic brain injury: insights into the treatment threshold. J Neurosurg 2018; 131:1216-1226. [PMID: 30497191 PMCID: PMC8979548 DOI: 10.3171/2018.4.jns172604] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/25/2017] [Accepted: 04/23/2018] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Brain tissue hypoxia is common after traumatic brain injury (TBI). Technology now exists that can detect brain hypoxia and guide corrective therapy. Current guidelines for the management of severe TBI recommend maintaining partial pressure of brain tissue oxygen (PbtO2) > 15-20 mm Hg; however, uncertainty persists as to the optimal treatment threshold. The object of this study was to better inform the relationship between PbtO2 values and outcome for patients with TBI. METHODS PbtO2 measurements were prospectively and automatically collected every minute from consecutive patients admitted to the San Francisco General Hospital neurological ICU during a 6-year period. Mean PbtO2 values in TBI patients as well as the proportion of PbtO2 values below each of 75 thresholds between 0 mm Hg and 75 mm Hg over various epochs up to 30 days from the time of admission were analyzed. Patient outcomes were determined using the Glasgow Outcome Scale. The authors explored putative treatment thresholds by generating 675 separate receiver operating characteristic curves and 675 generalized linear models to examine each 1-mm Hg threshold for various epochs. RESULTS A total of 1,380,841 PbtO2 values were recorded in 190 TBI patients. A high proportion of PbtO2 measures were below 20 mm Hg irrespective of the examined epoch. Time below treatment thresholds was more strongly associated with outcome than mean PbtO2. A treatment window was suggested: a threshold of 19 mm Hg most robustly distinguished patients by outcome, especially from days 3-5; however, benefit was suggested from maintaining values at least as high as 33 mm Hg. CONCLUSIONS This analysis of high-frequency physiological data substantially informs the relationship between PbtO2 values and outcome. The results suggest a therapeutic window for PbtO2 in TBI patients along with minimum and preferred PbtO2 treatment thresholds, which may be examined in future studies. Traditional treatment thresholds that have the strongest association with outcome may not be optimal.
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Affiliation(s)
- Ryan Hirschi
- School of Medicine, University of Utah, Salt Lake City
| | - Gregory W. J. Hawryluk
- Department of Neurological Surgery, Clinical Neurosciences Center, University of Utah, Salt Lake City, Utah
| | - Jessica L. Nielson
- Department of Psychiatry, Institute of Health Informatics, University of Minnesota Medical School, Minneapolis, Minnesota
| | - J. Russell Huie
- Brain and Spinal Injury Center, Weill Institute for Neurosciences, Department of Neurosurgery, San Francisco General Hospital, University of California, San Francisco
| | - Lara L. Zimmermann
- Department of Neurological Surgery, University of California, Davis, Sacramento, California
| | - Rajiv Saigal
- Department of Neurosurgery, University of Washington, Seattle, Washington
| | - Quan Ding
- Department of Physiologic Nursing, University of California, San Francisco, California
| | - Adam R. Ferguson
- Brain and Spinal Injury Center, Weill Institute for Neurosciences, Department of Neurosurgery, San Francisco General Hospital, University of California, San Francisco
| | - Geoffrey Manley
- Department of Neurological Surgery, University of California, San Francisco, California
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