1
|
de Moraes FM, Brasil S, Frigieri G, Robba C, Paiva W, Silva GS. ICP wave morphology as a screening test to exclude intracranial hypertension in brain-injured patients: a non-invasive perspective. J Clin Monit Comput 2024; 38:773-782. [PMID: 38355918 DOI: 10.1007/s10877-023-01120-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2023] [Accepted: 12/15/2023] [Indexed: 02/16/2024]
Abstract
Intracranial hypertension (IH) is a life-threating condition especially for the brain injured patient. In such cases, an external ventricular drain (EVD) or an intraparenchymal bolt are the conventional gold standard for intracranial pressure (ICPi) monitoring. However, these techniques have several limitations. Therefore, identifying an ideal screening method for IH is important to avoid the unnecessary placement of ICPi and expedite its introduction in patients who require it. A potential screening tool is the ICP wave morphology (ICPW) which changes according to the intracranial volume-pressure curve. Specifically, the P2/P1 ratio of the ICPW has shown promise as a triage test to indicate normal ICP. In this study, we propose evaluating the noninvasive ICPW (nICPW-B4C sensor) as a screening method for ICPi monitoring in patients with moderate to high probability of IH. This is a retrospective analysis of a prospective, multicenter study that recruited adult patients requiring ICPi monitoring from both Federal University of São Paulo and University of São Paulo Medical School Hospitals. ICPi values and the nICPW parameters were obtained from both the invasive and the noninvasive methods simultaneously 5 min after the closure of the EVD drainage. ICP assessment was performed using a catheter inserted into the ventricle and connected to a pressure transducer and a drainage system. The B4C sensor was positioned on the patient's scalp without the need for trichotomy, surgical incision or trepanation, and the morphology of the ICP waves acquired through a strain sensor that can detect and monitor skull bone deformations caused by changes in ICP. All patients were monitored using this noninvasive system for at least 10 min per session. The area under the curve (AUC) was used to describe discriminatory power of the P2/P1 ratio for IH, with emphasis in the Negative Predictive value (NPV), based on the Youden index, and the negative likelihood ratio [LR-]. Recruitment occurred from August 2017 to March 2020. A total of 69 patients fulfilled inclusion and exclusion criteria in the two centers and a total of 111 monitorizations were performed. The mean P2/P1 ratio value in the sample was 1.12. The mean P2/P1 value in the no IH population was 1.01 meanwhile in the IH population was 1.32 (p < 0.01). The best Youden index for the mean P2/P1 ratio was with a cut-off value of 1.13 showing a sensitivity of 93%, specificity of 60%, and a NPV of 97%, as well as an AUC of 0.83 to predict IH. With the 1.13 cut-off value for P2/P1 ratio, the LR- for IH was 0.11, corresponding to a strong performance in ruling out the condition (IH), with an approximate 45% reduction in condition probability after a negative test (ICPW). To conclude, the P2/P1 ratio of the noninvasive ICP waveform showed in this study a high Negative Predictive Value and Likelihood Ratio in different acute neurological conditions to rule out IH. As a result, this parameter may be beneficial in situations where invasive methods are not feasible or unavailable and to screen high-risk patients for potential invasive ICP monitoring.Trial registration: At clinicaltrials.gov under numbers NCT05121155 (Registered 16 November 2021-retrospectively registered) and NCT03144219 (Registered 30 September 2022-retrospectively registered).
Collapse
Affiliation(s)
| | - Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gustavo Frigieri
- Medical Investigation Laboratory 62, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Chiara Robba
- Anesthesia and Intensive Care, Ospedale Policlinico San Martino, IRCCS Per L'Oncologia E Le Neuroscienze, Genoa, Italy
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Gisele Sampaio Silva
- Department of Neurology and Neurosurgery, Federal University of São Paulo, São Paulo, Brazil
| |
Collapse
|
2
|
Bonfanti M, Lorini FL, Zangari R, Bonanomi E, Farina A, Pezzetti G, Gerevini S, Aresi S, Dell'Avanzo G, Micheli F, Lanterna LA, Biroli F, Gritti P. Intracranial Pressure Thresholds for Cerebral Autoregulation Impairment: Age-Stratified Analysis of Ultra-Low-Frequency Pressure Reactivity Index (UL-PRx) in Traumatic Brain Injury. Neurocrit Care 2024:10.1007/s12028-024-02056-5. [PMID: 39009939 DOI: 10.1007/s12028-024-02056-5] [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: 03/20/2024] [Accepted: 06/21/2024] [Indexed: 07/17/2024]
Abstract
BACKGROUND The study investigated the effectiveness of low-frequency sampling in detecting alterations in cerebrovascular reactivity (CVR) associated with changes in intracranial pressure (ICP) in patients with traumatic brain injury (TBI) across different age groups. The primary objective was to investigate an ICP threshold that indicates a decrease in CVR as evidenced by a significant increase in the ultra-low-frequency pressure reactivity index (UL-PRx). Additionally, the study aimed to develop an age-based categorization method for patients with TBI to investigate the differences between these ICP thresholds in different age groups. METHODS In this retrospective analysis, data from 263 patients with TBI were prospectively collected. ICP and mean arterial pressure were extracted from the hospital database at 5-min intervals. Demographic details, clinical presentation, computed tomography scans, neurosurgical interventions, and 12-months outcome were recorded. ICP versus UL-PRx values were categorized into ICP bins and graphically represented with boxplots for each age group, illustrating how as ICP values rise, there is a bin (age-tailored ICP [AT-ICP]) beyond which UL-PRx shows a sudden increase, indicating CVR loss. Homogeneous age groups were established to obtain a consistent AT-ICP threshold. The discriminatory ability of the AT-ICP thresholds was compared with the guideline-recommended thresholds by calculating the area under the Receiver Operating Characteristic curve of the ICP-derived indices (dose above threshold, and the hourly dosage above threshold). RESULTS Age groups 0-5, 6-20, 21-60, 61-70, and 71-85 years were the best age subdivisions, corresponding to AT-ICP thresholds of 20, 30, 35, 25, and 30 mmHg, respectively. The AT-ICP thresholds exhibited better discriminative ability compared with the guideline-recommended thresholds. CONCLUSIONS The AT-ICP thresholds offer a novel approach for estimating CVR impairment and the developed method represents an alternative solution to address the age stratification issue in patients with TBI.
Collapse
Affiliation(s)
- Marco Bonfanti
- FROM Research Foundation- ETS, Papa Giovanni XXIII Hospital, Piazza OSM 1, 24129, Bergamo, Italy.
| | - Ferdinando Luca Lorini
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Rosalia Zangari
- FROM Research Foundation- ETS, Papa Giovanni XXIII Hospital, Piazza OSM 1, 24129, Bergamo, Italy
| | - Ezio Bonanomi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Alessia Farina
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giulio Pezzetti
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Simonetta Gerevini
- Department of Neuroradiology, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Silvia Aresi
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Giacomo Dell'Avanzo
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | - Fabio Micheli
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| | | | - Francesco Biroli
- FROM Research Foundation- ETS, Papa Giovanni XXIII Hospital, Piazza OSM 1, 24129, Bergamo, Italy
| | - Paolo Gritti
- Department of Anesthesia and Critical Care Medicine, Papa Giovanni XXIII Hospital, Bergamo, Italy
| |
Collapse
|
3
|
Stein KY, Amenta F, Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Ibrahim Y, Islam A, Bergmann T, Marquez I, Zeiler FA. Associations Between Intracranial Pressure Extremes and Continuous Metrics of Cerebrovascular Pressure Reactivity in Acute Traumatic Neural Injury: A Scoping Review. Neurotrauma Rep 2024; 5:483-496. [PMID: 39036433 PMCID: PMC11257139 DOI: 10.1089/neur.2023.0115] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 07/23/2024] Open
Abstract
Cerebrovascular pressure reactivity plays a key role in maintaining constant cerebral blood flow. Unfortunately, this mechanism is often impaired in acute traumatic neural injury states, exposing the already injured brain to further pressure-passive insults. While there has been much work on the association between impaired cerebrovascular reactivity following moderate/severe traumatic brain injury (TBI) and worse long-term outcomes, there is yet to be a comprehensive review on the association between cerebrovascular pressure reactivity and intracranial pressure (ICP) extremes. Therefore, we conducted a systematic review of the literature for all studies presenting a quantifiable statistical association between a continuous measure of cerebrovascular pressure reactivity and ICP in a human TBI cohort. The methodology described in the Cochrane Handbook for Systematic Reviews was used. BIOSIS, Cochrane Library, EMBASE, Global Health, MEDLINE, and SCOPUS were all searched from their inceptions to March of 2023 for relevant articles. Full-length original works with a sample size of ≥10 patients with moderate/severe TBI were included in this review. Data were reported in accordance with the Preferred Reporting Items for Systematic Reviews and Meta-Analyses. A total of 16 articles were included in this review. Studies varied in population characteristics and statistical tests used. Five studies looked at transcranial Doppler-based indices and 13 looked at ICP-based indices. All but two studies were able to present a statistically significant association between cerebrovascular pressure reactivity and ICP. Based on the findings of this review, impaired reactivity seems to be associated with elevated ICP and reduced ICP waveform complexity. This relationship may allow for the calculation of patient-specific ICP thresholds, past which cerebrovascular reactivity becomes persistently deranged. However, further work is required to better understand this relationship and improve algorithmic derivation of such individualized ICP thresholds.
Collapse
Affiliation(s)
- Kevin Y. Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- 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
| | - 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
| | - Younis Ibrahim
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Abrar Islam
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Tobias Bergmann
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Izabella Marquez
- Undergraduate 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 Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
4
|
Brasil S, Godoy DA, Videtta W, Rubiano AM, Solla D, Taccone FS, Robba C, Rasulo F, Aries M, Smielewski P, Meyfroidt G, Battaglini D, Hirzallah MI, Amorim R, Sampaio G, Moulin F, Deana C, Picetti E, Kolias A, Hutchinson P, Hawryluk GW, Czosnyka M, Panerai RB, Shutter LA, Park S, Rynkowski C, Paranhos J, Silva THS, Malbouisson LMS, Paiva WS. A Comprehensive Perspective on Intracranial Pressure Monitoring and Individualized Management in Neurocritical Care: Results of a Survey with Global Experts. Neurocrit Care 2024:10.1007/s12028-024-02008-z. [PMID: 38811514 DOI: 10.1007/s12028-024-02008-z] [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: 02/23/2024] [Accepted: 05/01/2024] [Indexed: 05/31/2024]
Abstract
BACKGROUND Numerous trials have addressed intracranial pressure (ICP) management in neurocritical care. However, identifying its harmful thresholds and controlling ICP remain challenging in terms of improving outcomes. Evidence suggests that an individualized approach is necessary for establishing tolerance limits for ICP, incorporating factors such as ICP waveform (ICPW) or pulse morphology along with additional data provided by other invasive (e.g., brain oximetry) and noninvasive monitoring (NIM) methods (e.g., transcranial Doppler, optic nerve sheath diameter ultrasound, and pupillometry). This study aims to assess current ICP monitoring practices among experienced clinicians and explore whether guidelines should incorporate ancillary parameters from NIM and ICPW in future updates. METHODS We conducted a survey among experienced professionals involved in researching and managing patients with severe injury across low-middle-income countries (LMICs) and high-income countries (HICs). We sought their insights on ICP monitoring, particularly focusing on the impact of NIM and ICPW in various clinical scenarios. RESULTS From October to December 2023, 109 professionals from the Americas and Europe participated in the survey, evenly distributed between LMIC and HIC. When ICP ranged from 22 to 25 mm Hg, 62.3% of respondents were open to considering additional information, such as ICPW and other monitoring techniques, before adjusting therapy intensity levels. Moreover, 77% of respondents were inclined to reassess patients with ICP in the 18-22 mm Hg range, potentially escalating therapy intensity levels with the support of ICPW and NIM. Differences emerged between LMIC and HIC participants, with more LMIC respondents preferring arterial blood pressure transducer leveling at the heart and endorsing the use of NIM techniques and ICPW as ancillary information. CONCLUSIONS Experienced clinicians tend to personalize ICP management, emphasizing the importance of considering various monitoring techniques. ICPW and noninvasive techniques, particularly in LMIC settings, warrant further exploration and could potentially enhance individualized patient care. The study suggests updating guidelines to include these additional components for a more personalized approach to ICP management.
Collapse
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil.
| | | | - Walter Videtta
- Intensive Care Unit, Hospital Posadas, Buenos Aires, Argentina
| | | | - Davi Solla
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hôpital Universitaire de Bruxelles, Université Libre de Bruxelles, Brussels, Belgium
| | - Chiara Robba
- Anesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare, Policlínico San Martino, Genoa, Italy
| | - Frank Rasulo
- Neuroanesthesia, Neurocritical and Postoperative Care, Spedali Civili University Affiliated Hospital of Brescia, Brescia, Italy
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Peter Smielewski
- Department of Clinical Neurosciences, Addenbrookes Hospital, University of Cambridge, Cambridge, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
| | - Denise Battaglini
- Anesthesia and Intensive Care, Scientific Institute for Research, Hospitalization and Healthcare, Policlínico San Martino, Genoa, Italy
| | - Mohammad I Hirzallah
- Departments of Neurology, Neurosurgery, and Center for Space Medicine, Baylor College of Medicine, Houston, TX, USA
| | - Robson Amorim
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Gisele Sampaio
- Neurology Department, São Paulo Federal University Medical School, São Paulo, Brazil
| | - Fabiano Moulin
- Neurology Department, São Paulo Federal University Medical School, São Paulo, Brazil
| | - Cristian Deana
- Department of Anesthesia and Intensive Care, Health Integrated Agency of Friuli Centrale, Udine, Italy
| | - Edoardo Picetti
- Department of Anesthesia and Intensive Care, Parma University Hospital, Parma, Italy
| | | | | | - Gregory W Hawryluk
- Cleveland Clinic Neurological Institute, Akron General Hospital, Fairlawn, OH, USA
- Uniformed Services University, Bethesda, USA
- Brain Trauma Foundation, New York, USA
| | - Marek Czosnyka
- Division of Neurosurgery, Addenbrooke's Hospital, Cambridge, UK
| | - Ronney B Panerai
- Cerebral Haemodynamics in Ageing and Stroke Medicine Group, Department of Cardiovascular Sciences, University of Leicester, Leicester, UK
| | - Lori A Shutter
- Departments of Critical Care Medicine, Neurology and Neurosurgery, University of Pittsburgh School of Medicine, Pittsburgh, PA, USA
| | - Soojin Park
- Departments of Neurology and Biomedical Informatics, Columbia University Vagelos College of Physicians and Surgeons, New York-Presbyterian Hospital, New York, NY, USA
| | - Carla Rynkowski
- Department of Urgency and Trauma, Medical Faculty, Federal University of Health Sciences of Porto Alegre, Porto Alegre, Brazil
| | - Jorge Paranhos
- Intensive Care and Neuroemergency, Santa Casa de Misericórdia, São João del Rei, Brazil
| | - Thiago H S Silva
- Department of Intensive Care, School of Medicine University of São Paulo, São Paulo, Brazil
| | - Luiz M S Malbouisson
- Department of Intensive Care, School of Medicine University of São Paulo, São Paulo, Brazil
| | - Wellingson S Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| |
Collapse
|
5
|
Muehlschlegel S, Rajajee V, Wartenberg KE, Alexander SA, Busl KM, Creutzfeldt CJ, Fontaine GV, Hocker SE, Hwang DY, Kim KS, Madzar D, Mahanes D, Mainali S, Meixensberger J, Sakowitz OW, Varelas PN, Weimar C, Westermaier T. Guidelines for Neuroprognostication in Critically Ill Adults with Moderate-Severe Traumatic Brain Injury. Neurocrit Care 2024; 40:448-476. [PMID: 38366277 PMCID: PMC10959796 DOI: 10.1007/s12028-023-01902-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/17/2023] [Accepted: 11/22/2023] [Indexed: 02/18/2024]
Abstract
BACKGROUND Moderate-severe traumatic brain injury (msTBI) carries high morbidity and mortality worldwide. Accurate neuroprognostication is essential in guiding clinical decisions, including patient triage and transition to comfort measures. Here we provide recommendations regarding the reliability of major clinical predictors and prediction models commonly used in msTBI neuroprognostication, guiding clinicians in counseling surrogate decision-makers. METHODS Using the Grading of Recommendations Assessment, Development, and Evaluation (GRADE) methodology, we conducted a systematic narrative review of the most clinically relevant predictors and prediction models cited in the literature. The review involved framing specific population/intervention/comparator/outcome/timing/setting (PICOTS) questions and employing stringent full-text screening criteria to examine the literature, focusing on four GRADE criteria: quality of evidence, desirability of outcomes, values and preferences, and resource use. Moreover, good practice recommendations addressing the key principles of neuroprognostication were drafted. RESULTS After screening 8125 articles, 41 met our eligibility criteria. Ten clinical variables and nine grading scales were selected. Many articles varied in defining "poor" functional outcomes. For consistency, we treated "poor" as "unfavorable". Although many clinical variables are associated with poor outcome in msTBI, only the presence of bilateral pupillary nonreactivity on admission, conditional on accurate assessment without confounding from medications or injuries, was deemed moderately reliable for counseling surrogates regarding 6-month functional outcomes or in-hospital mortality. In terms of prediction models, the Corticosteroid Randomization After Significant Head Injury (CRASH)-basic, CRASH-CT (CRASH-basic extended by computed tomography features), International Mission for Prognosis and Analysis of Clinical Trials in TBI (IMPACT)-core, IMPACT-extended, and IMPACT-lab models were recommended as moderately reliable in predicting 14-day to 6-month mortality and functional outcomes at 6 months and beyond. When using "moderately reliable" predictors or prediction models, the clinician must acknowledge "substantial" uncertainty in the prognosis. CONCLUSIONS These guidelines provide recommendations to clinicians on the formal reliability of individual predictors and prediction models of poor outcome when counseling surrogates of patients with msTBI and suggest broad principles of neuroprognostication.
Collapse
Affiliation(s)
- Susanne Muehlschlegel
- Departments of Neurology and Anesthesiology/Critical Care Medicine, Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | | | | | | | - Katharina M Busl
- Departments of Neurology and Neurosurgery, University of Florida College of Medicine, Gainesville, FL, USA
| | | | - Gabriel V Fontaine
- Departments of Pharmacy and Neurosciences, Intermountain Health, Salt Lake City, UT, USA
| | - Sara E Hocker
- Department of Neurology, Saint Luke's Health System, Kansas City, MO, USA
| | - David Y Hwang
- Department of Neurology, University of North Carolina at Chapel Hill, Chapel Hill, NC, USA
| | - Keri S Kim
- Department of Pharmacy Practice, University of Illinois at Chicago, Chicago, IL, USA
| | - Dominik Madzar
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany
| | - Dea Mahanes
- Departments of Neurology and Neurosurgery, University of Virginia Health, Charlottesville, VA, USA
| | - Shraddha Mainali
- Department of Neurology, Virginia Commonwealth University, Richmond, VA, USA
| | | | - Oliver W Sakowitz
- Department of Neurosurgery, Neurosurgery Center Ludwigsburg-Heilbronn, Ludwigsburg, Germany
| | | | - Christian Weimar
- Institute of Medical Informatics, Biometry, and Epidemiology, University Hospital Essen, Essen, Germany
- BDH-Klinik Elzach, Elzach, Germany
| | - Thomas Westermaier
- Department of Neurosurgery, Helios Amper Klinikum Dachau, Dachau, Germany.
- Faculty of Medicine, University of Würzburg, Würzburg, Germany.
| |
Collapse
|
6
|
Stein KY, Froese L, Sekhon M, Griesdale D, Thelin EP, Raj R, Tas J, Aries M, Gallagher C, Bernard F, Gomez A, Kramer AH, Zeiler FA. Intracranial Pressure-Derived Cerebrovascular Reactivity Indices and Their Critical Thresholds: A Canadian High Resolution-Traumatic Brain Injury Validation Study. J Neurotrauma 2024; 41:910-923. [PMID: 37861325 DOI: 10.1089/neu.2023.0374] [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] [Indexed: 10/21/2023] Open
Abstract
Current neurointensive care guidelines recommend intracranial pressure (ICP) and cerebral perfusion pressure (CPP) centered management for moderate-severe traumatic brain injury (TBI) because of their demonstrated associations with patient outcome. Cerebrovascular reactivity metrics, such as the pressure reactivity index (PRx), pulse amplitude index (PAx), and RAC index, have also demonstrated significant prognostic capabilities with regard to outcome. However, critical thresholds for cerebrovascular reactivity indices have only been identified in two studies conducted at the same center. In this study, we aim to determine the critical thresholds of these metrics by leveraging a unique multi-center database. The study included a total of 354 patients from the CAnadian High-Resolution TBI (CAHR-TBI) Research Collaborative. Based on 6-month Glasgow Outcome Scores, patients were dichotomized into alive versus dead and favorable versus unfavorable. Chi-square values were then computed for incrementally increasing values of each physiological parameter of interest against outcome. The values that generated the greatest chi-squares for each parameter were considered to be the thresholds with the greatest outcome discriminatory capacity. To confirm that the identified thresholds provide prognostic utility, univariate and multivariable logistical regression analyses were performed adjusting for the International Mission for Prognosis and Analysis of Clinical Trials (IMPACT) variables. Through the chi-square analysis, a lower limit CPP threshold of 60 mm Hg and ICP thresholds of 18 mm Hg and 22 mm Hg were identified for both survival and favorable outcome predictions. For the cerebrovascular reactivity metrics, different thresholds were identified for the two outcome dichotomizations. For survival prediction, thresholds of 0.35, 0.25, and 0 were identified for PRx, PAx, and RAC, respectively. For favorable outcome prediction, thresholds of 0.325, 0.20, and 0.05 were found. Univariate logistical regression analysis demonstrated that the time spent above/below thresholds were associated with outcome. Further, multivariable logistical regression analysis found that percent time above/below the identified thresholds added additional variance to the IMPACT core model for predicting both survival and favorable outcome. In this study, we were able to validate the results of the previous two works as well as to reaffirm the ICP and CPP guidelines from the Brain Trauma Foundation (BTF) and the Seattle International Severe Traumatic Brain Injury Consensus Conference (SIBICC).
Collapse
Affiliation(s)
- Kevin Y Stein
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Mypinder Sekhon
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Donald Griesdale
- Department of Anesthesiology, Pharmacology, and Therapeutics, University of British Columbia, Vancouver, British Columbia, Canada
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Jeanette Tas
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center+, and School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- Section of Neurosurgery, University of Calgary, Calgary, Alberta, Canada
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
| | - Francis Bernard
- Section of Critical Care, Department of Medicine, University of Montreal, Montreal, Quebec, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Andreas H Kramer
- Department of Clinical Neurosciences, University of Calgary, Calgary, Alberta, Canada
- Hotchkiss Brain Institute, University of Calgary, Calgary, Alberta, Canada
- Department of Critical Care Medicine, University of Calgary, Calgary, Alberta, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
7
|
Lazaridis C, Foreman B. Management Strategies Based on Multi-Modality Neuromonitoring in Severe Traumatic Brain Injury. Neurotherapeutics 2023; 20:1457-1471. [PMID: 37491682 PMCID: PMC10684466 DOI: 10.1007/s13311-023-01411-2] [Citation(s) in RCA: 4] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/14/2023] [Indexed: 07/27/2023] Open
Abstract
Secondary brain injury after neurotrauma is comprised of a host of distinct, potentially concurrent and interacting mechanisms that may exacerbate primary brain insult. Multimodality neuromonitoring is a method of measuring multiple aspects of the brain in order to understand the signatures of these different pathomechanisms and to detect, treat, or prevent potentially reversible secondary brain injuries. The most studied invasive parameters include intracranial pressure (ICP), cerebral perfusion pressure (CPP), autoregulatory indices, brain tissue partial oxygen tension, and tissue energy and metabolism measures such as the lactate pyruvate ratio. Understanding the local metabolic state of brain tissue in order to infer pathology and develop appropriate management strategies is an area of active investigation. Several clinical trials are underway to define the role of brain tissue oxygenation monitoring and electrocorticography in conjunction with other multimodal neuromonitoring information, including ICP and CPP monitoring. Identifying an optimal CPP to guide individualized management of blood pressure and ICP has been shown to be feasible, but definitive clinical trial evidence is still needed. Future work is still needed to define and clinically correlate patterns that emerge from integrated measurements of metabolism, pressure, flow, oxygenation, and electrophysiology. Pathophysiologic targets and precise critical care management strategies to address their underlying causes promise to mitigate secondary injuries and hold the potential to improve patient outcome. Advancements in clinical trial design are poised to establish new standards for the use of multimodality neuromonitoring to guide individualized clinical care.
Collapse
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
| | - Brandon Foreman
- Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA
| |
Collapse
|
8
|
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.
Collapse
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
| |
Collapse
|
9
|
Sanchez-Porras R, Ramírez-Cuapio FL, Hecht N, Seule M, Díaz-Peregrino R, Unterberg A, Woitzik J, Dreier JP, Sakowitz OW, Santos E. Cerebrovascular Pressure Reactivity According to Long-Pressure Reactivity Index During Spreading Depolarizations in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:135-144. [PMID: 36697998 PMCID: PMC10499750 DOI: 10.1007/s12028-022-01669-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Spreading depolarization (SD) has been linked to the impairment of neurovascular coupling. However, the association between SD occurrence and cerebrovascular pressure reactivity as a surrogate of cerebral autoregulation (CA) remains unclear. Therefore, we analyzed CA using the long-pressure reactivity index (L-PRx) during SDs in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective study of patients with aSAH who were recruited at two centers, Heidelberg (HD) and Berlin (BE), was performed. Continuous monitoring of mean arterial pressure (MAP) and intracranial pressure (ICP) was recorded. ICP was measured using an intraparenchymal probe in HD patients and was measure in BE patients through external ventricular drainage. Electrocorticographic (ECoG) activity was continuously recorded between 3 and 13 days after hemorrhage. Autoregulation according to L-PRx was calculated as a moving linear Pearson's correlation of 20-min averages of MAP and ICP. For every identified SD, 60-min intervals of L-PRx were averaged, plotted, and analyzed depending on SD occurrence. Random L-PRx recording periods without SDs served as the control. RESULTS A total of 19 patients (HD n = 14, BE n = 5, mean age 50.4 years, 9 female patients) were monitored for a mean duration of 230.4 h (range 96-360, STD ± 69.6 h), during which ECoG recordings revealed a total number of 277 SDs. Of these, 184 represented a single SD, and 93 SDs presented in clusters. In HD patients, mean L-PRx values were 0.12 (95% confidence interval [CI] 0.11-0.13) during SDs and 0.07 (95% CI 0.06-0.08) during control periods (p < 0.001). Similarly, in BE patients, a higher L-PRx value of 0.11 (95% CI 0.11-0.12) was detected during SDs than that during control periods (0.08, 95% CI 0.07-0.09; p < 0.001). In a more detailed analysis, CA changes registered through an intraparenchymal probe (HD patients) revealed that clustered SD periods were characterized by signs of more severely impaired CA (L-PRx during SD in clusters: 0.23 [95% CI 0.20-0.25]; single SD: 0.09 [95% CI 0.08-0.10]; control periods: 0.07 [95% CI 0.06-0.08]; p < 0.001). This group also showed significant increases in ICP during SDs in clusters compared with single SD and control periods. CONCLUSIONS Neuromonitoring for simultaneous assessment of cerebrovascular pressure reactivity using 20-min averages of MAP and ICP measured by L-PRx during SD events is feasible. SD occurrence was associated with significant increases in L-PRx values indicative of CA disturbances. An impaired CA was found during SD in clusters when using an intraparenchymal probe. This preliminary study validates the use of cerebrovascular reactivity indices to evaluate CA disturbances during SDs. Our results warrant further investigation in larger prospective patient cohorts.
Collapse
Affiliation(s)
- Renan Sanchez-Porras
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Francisco L Ramírez-Cuapio
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Seule
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roberto Díaz-Peregrino
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany.
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
| |
Collapse
|
10
|
Xie J, Burrows BT, Fox Kensicki J, Adelson PD, Appavu B. Early Electroencephalographic Features Predicting Cerebral Physiology and Functional Outcomes After Pediatric Traumatic Brain Injury. Neurocrit Care 2023; 38:657-666. [PMID: 36329306 DOI: 10.1007/s12028-022-01633-w] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/22/2022] [Accepted: 10/14/2022] [Indexed: 11/06/2022]
Abstract
BACKGROUND We investigated whether early electroencephalographic features predicted intracranial pressure (ICP), cerebrovascular pressure reactivity, brain tissue oxygenation, and functional outcomes in patients with pediatric traumatic brain injury (TBI). METHODS This was a retrospective analysis of a prospective data set of 63 patients with pediatric TBI. Electroencephalographic features were collected in the first 24 h of recording to predict values of ICP, pressure reactivity index (PRx), and brain tissue oxygenation (PbtO2) through the initial 7 days of critical care monitoring, in addition to Glasgow Outcome Scale Extended-Pediatric Revision (GOSE-Peds) scores at 12 months. Electroencephalographic features were averaged over all surface electrodes and included seizures, interictal epileptiform discharges, suppression percentage, complexity, the alpha/delta power ratio, and both absolute asymmetry indices and power in beta (13-20 Hz), alpha (8-13 Hz), theta (4-7 Hz) and delta (0-4 Hz) bands. Demographic data and injury severity scores, such as the Glasgow Coma Scale (GCS) and Pediatric Risk of Mortality III (PRISM III) scores, at presentation were also assessed. Univariate and multiple linear regression with guided stepwise variable selection was used to find combinations of risk factors that best explain variability in ICP, PRx, PbtO2, and GOSE-Peds values, and best fit models were applied to pediatric age strata. We hypothesized that suppression percentage and the alpha/delta power ratio in the first 24 h of recording predict ICP, PRx, PbtO2, and GOSE-Peds values. RESULTS Best subset model selection identified that increased suppression percentage and PRISM III scores predicted increased ICP (R2 = 79%, Akaike information criterion [AIC] = 332.30, root mean square error [RMSE] = 6.62), with suppression percentages < 5% (slope = - 5687.0, p = 0.0001) and ≥ 45% (slope = 9825.9, p = 0.0000) being predictive of dose of intracranial hypertension. When accounting for age and GCS score, increased suppression percentage predicted increased PRx values, suggestive of inefficient cerebrovascular pressure reactivity (R2 = 53%, AIC = 3.93, RMSE = 0.23), with suppression percentages ≥ 5% (p = 0.0033) and ≥ 45% (p = 0.0027) being predictive of median PRx values ≥ 0.3. Lower GCS scores, the presence of seizures, and increased suppression percentages each were independently associated with higher GOSE-Peds scores (R2 = 52%, AIC = 194.04, RMSE = 1.58), suggestive of unfavorable outcomes, with suppression percentages ≥ 5% (p = 0.0005) and ≥ 45% (p = 0.0000) being predictive of GOSE-Peds scores ≥ 5. At the univariate level, no electroencephalographic or clinical feature was associated with differences in PbtO2 values. CONCLUSIONS Increased electroencephalographic suppression percentage on the initial day of monitoring may identify patients with pediatric TBI at risk of increased ICP, inefficient cerebrovascular pressure reactivity, and unfavorable outcomes.
Collapse
Affiliation(s)
- Jinnie Xie
- Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E. Van Buren Street , Phoenix, AZ, USA
| | - Brian T Burrows
- Department of Neurosciences, Phoenix Children's Hospital, 1919 E. Thomas Road Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Jordana Fox Kensicki
- Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E. Van Buren Street , Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, 1919 E. Thomas Road Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - P David Adelson
- Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E. Van Buren Street , Phoenix, AZ, USA
- Department of Neurosciences, Phoenix Children's Hospital, 1919 E. Thomas Road Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Brian Appavu
- Department of Child Health, University of Arizona College of Medicine - Phoenix, 550 E. Van Buren Street , Phoenix, AZ, USA.
- Department of Neurosciences, Phoenix Children's Hospital, 1919 E. Thomas Road Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.
| |
Collapse
|
11
|
Shim Y, Kim J, Kim HS, Oh J, Lee S, Ha EJ. Intracranial Pressure Monitoring for Acute Brain Injured Patients: When, How, What Should We Monitor. Korean J Neurotrauma 2023; 19:149-161. [PMID: 37431379 PMCID: PMC10329885 DOI: 10.13004/kjnt.2023.19.e32] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2023] [Revised: 06/13/2023] [Accepted: 06/16/2023] [Indexed: 07/12/2023] Open
Abstract
While there is no level I recommendation for intracranial pressure (ICP) monitoring, it is typically indicated for patients with severe traumatic brain injury (TBI) with a Glasgow Coma Scale (GCS) score of 3-8 (class II). Even for moderate TBI patients with GCS 9-12, ICP monitoring should be considered for risk of increased ICP. The impact of ICP monitoring on patient outcomes is still not well-established, but recent studies reported a reduction of early mortality (class III) in TBI patients. There is no standard protocol for the application of ICP monitoring. In cases where cerebrospinal fluid drainage is required, an external ventricular drain is commonly used. In other cases, parenchymal ICP monitoring devices are generally employed. Subdural or non-invasive forms are not suitable for ICP monitoring. The mean value of ICP is the parameter recommended for observation in many guidelines. In TBI, values above 22 mmHg are associated with increased mortality. However, recent studies proposed various parameters including cumulative time with ICP above 20 mmHg (pressure-time dose), pressure reactivity index, ICP waveform characteristics (pulse amplitude of ICP, mean ICP wave amplitude), and the compensatory reserve of the brain (reserve-amplitude-pressure), which are useful in predicting patient outcomes and guiding treatment. Further research is required for validation of these parameters compared to simple ICP monitoring.
Collapse
Affiliation(s)
- Youngbo Shim
- Department of Critical Care Medicine, Kangbuk Samsung Hospital, Seoul, Korea
| | - Jungook Kim
- Gachon University Gil Hospital Regional Trauma Center, Gachon, Korea
| | - Hye Seon Kim
- Department of Neurosurgery, Incheon St. Mary’s Hospital, College of Medicine, The Catholic University, Incheon, Korea
| | - Jiwoong Oh
- Departments of Neurological Surgery and Critical Care Medicine, Severance Hospital, Yonsei University College of Medicine, Seoul, Korea
| | - Seungioo Lee
- Departments of Neurological Surgery and Critical Care Medicine, Asan Medical Center, University of Ulsan College of Medicine, Seoul, Korea
| | - Eun Jin Ha
- Department of Critical Care Medicine, Seoul National University Hospital, Seoul National University College of Medicine, Seoul, Korea
| |
Collapse
|
12
|
Froese L, Gomez A, Sainbhi AS, Vakitbilir N, Marquez I, Amenta F, Stein KY, Zeiler FA. Temporal relationship between vasopressor and sedative administration and cerebrovascular response in traumatic brain injury: a time-series analysis. Intensive Care Med Exp 2023; 11:30. [PMID: 37246179 DOI: 10.1186/s40635-023-00515-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 04/21/2023] [Indexed: 05/30/2023] Open
Abstract
BACKGROUND Although vasopressor and sedative agents are commonly used within the intensive care unit to mediate systemic and cerebral physiology, the full impact such agents have on cerebrovascular reactivity remains unclear. Using a prospectively maintained database of high-resolution critical care and physiology, the time-series relationship between vasopressor/sedative administration, and cerebrovascular reactivity was interrogated. Cerebrovascular reactivity was assessed through intracranial pressure and near infrared spectroscopy measures. Using these derived measures, the relationship between hourly dose of medication and hourly index values could be evaluated. The individual medication dose change and their corresponding physiological response was compared. Given the high number of doses of propofol and norepinephrine, a latent profile analysis was used to identify any underlying demographic or variable relationships. Finally, using time-series methodologies of Granger causality and vector impulse response functions, the relationships between the cerebrovascular reactivity derived variables were compared. RESULTS From this retrospective observational study of 103 TBI patients, the evaluation between the changes in vasopressor or sedative agent dosing and the previously described cerebral physiologies was completed. The assessment of the physiology pre/post infusion agent change resulted in similar overall values (Wilcoxon signed-ranked p value > 0.05). Time series methodologies demonstrated that the basic physiological relationships were identical before and after an infusion agent was changed (Granger causality demonstrated the same directional impact in over 95% of the moments, with response function being graphically identical). CONCLUSIONS This study suggests that overall, there was a limited association between the changes in vasopressor or sedative agent dosing and the previously described cerebral physiologies including that of cerebrovascular reactivity. Thus, current regimens of administered sedative and vasopressor agents appear to have little to no impact on cerebrovascular reactivity in TBI.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada.
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
| | - Amanjyot Singh Sainbhi
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Nuray Vakitbilir
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
| | - Izabella Marquez
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Fiorella Amenta
- Undergraduate Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Kevin Y Stein
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Undergraduate Medical Education, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Division 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
| |
Collapse
|
13
|
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: 3] [Impact Index Per Article: 3.0] [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.
Collapse
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
| |
Collapse
|
14
|
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.
Collapse
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
| |
Collapse
|
15
|
Ballestero M, Dias C, Gomes ICN, Grisi LS, Cardoso RAM, Júnior ELZ, de Oliveira RS. Can a new noninvasive method for assessment of intracranial pressure predict intracranial hypertension and prognosis? Acta Neurochir (Wien) 2023; 165:1495-1503. [PMID: 37061612 PMCID: PMC10105611 DOI: 10.1007/s00701-023-05580-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2023] [Accepted: 04/04/2023] [Indexed: 04/17/2023]
Abstract
PURPOSE Individuals with TBI are at risk of intracranial hypertension (ICH), and monitoring of intracranial pressure (ICP) is usually indicated. However, despite many new noninvasive devices, none is sufficiently accurate and effective for application in clinical practice, particularly in the management of TBIs. This study aimed to compare the noninvasive Brain4Care system (nICP) with invasive ICP (iICP) curve parameters in their ability to predict ICH and functional prognosis in severe TBI. METHODS Observational, descriptive-analytical, and prospective study of 22 patients between 2018 and 2021, simultaneously monitored with nICP and iICP. The independent variables evaluated were the presence of ICH and functional prognoses. The dependent variables were the P2/P1 pressure ratio metrics, time to peak (TTP), and TTP × P2/P1. RESULTS We found a good nonlinear correlation between iICP and nICP waveforms, despite a moderate Pearson's linear correlation. The noninvasive parameters of P2/P1, P2/P1 × TTP, and TTP were not associated with outcomes or ICH. The nICP P2/P1 ratio showed sensitivity/specificity/accuracy (%) of 100/0/56.3, respectively for 1-month outcomes and 77.8/22.2/50 for 6-month outcomes. The nICP TTP ratio had values of 100/0/56.3 for 1-month and 99.9/42.9/72.2 for 6-month outcomes. The nICP P2/P1 × TTP values were 100/0/56.3 for 1-month outcomes and 81.8/28.6/61.1 for 6-month outcomes. CONCLUSION Brain4Care's noninvasive method showed low specificity and accuracy and cannot be used as the sole means of monitoring ICP in patients with severe TBI. Future studies with a larger sample of patients with P2 > P1 and new nICP curve parameters are warranted.
Collapse
Affiliation(s)
- Matheus Ballestero
- Department of Medicine, Federal University of São Carlos, São Carlos, Brazil.
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil.
| | - Celeste Dias
- Hospital São João, University of Porto, Porto, Portugal
| | | | - Luca Soares Grisi
- Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | | | | |
Collapse
|
16
|
Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2023:S2173-5808(23)00008-1. [PMID: 37031799 DOI: 10.1016/j.nrleng.2020.08.024] [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: 02/17/2020] [Accepted: 08/04/2020] [Indexed: 04/11/2023] Open
Abstract
INTRODUCTION Increased intracranial pressure (ICP) has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury (TBI). Traditionally, ICP-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe TBI in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
Collapse
Affiliation(s)
- César E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, USA.
| | - Nadxielli Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
| |
Collapse
|
17
|
Carra G, Güiza F, Piper I, Citerio G, Maas A, Depreitere B, Meyfroidt G. Development and External Validation of a Machine Learning Model for the Early Prediction of Doses of Harmful Intracranial Pressure in Patients with Severe Traumatic Brain Injury. J Neurotrauma 2023; 40:514-522. [PMID: 35950615 DOI: 10.1089/neu.2022.0251] [Citation(s) in RCA: 12] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Abstract
Treatment and prevention of elevated intracranial pressure (ICP) is crucial in patients with severe traumatic brain injury (TBI). Elevated ICP is associated with secondary brain injury, and both intensity and duration of an episode of intracranial hypertension, often referred to as "ICP dose," are associated with worse outcomes. Prediction of such harmful episodes of ICP dose could allow for a more proactive and preventive management of TBI, with potential implications on patients' outcomes. The goal of this study was to develop and validate a machine-learning (ML) model to predict potentially harmful ICP doses in patients with severe TBI. The prediction target was defined based on previous studies and included a broad range of doses of elevated ICP that have been associated with poor long-term neurological outcomes. The ML models were used, with minute-by-minute ICP and mean arterial blood pressure signals as inputs. Harmful ICP episodes were predicted with a 30 min forewarning. Models were developed in a multi-center dataset of 290 adult patients with severe TBI and externally validated on 264 patients from the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) dataset. The external validation of the prediction model on the CENTER-TBI dataset demonstrated good discrimination and calibration (area under the curve: 0.94, accuracy: 0.89, precision: 0.87, sensitivity: 0.78, specificity: 0.94, calibration-in-the-large: 0.03, calibration slope: 0.93). The proposed prediction model provides accurate and timely predictions of harmful doses of ICP on the development and external validation dataset. A future interventional study is needed to assess whether early intervention on the basis of ICP dose predictions will result in improved outcomes.
Collapse
Affiliation(s)
- Giorgia Carra
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, and UZ Leuven and KU Leuven, Leuven, Belgium
| | - Fabian Güiza
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, and UZ Leuven and KU Leuven, Leuven, Belgium
| | - Ian Piper
- Intensive Care Monitoring Research and Paediatric Critical Care, Edinburgh Royal Hospital for Children and Young People, Edinburgh, United Kingdom
| | - Giuseppe Citerio
- University of Milan-Bicocca, School of Medicine and Surgery and Department of Emergency and Intensive Care, Monza, Italy
| | - Andrew Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Bart Depreitere
- Department of Neurosurgery, UZ Leuven and KU Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Clinical Division and Laboratory of Intensive Care Medicine, Department of Cellular and Molecular Medicine, and UZ Leuven and KU Leuven, Leuven, Belgium
| | | |
Collapse
|
18
|
Svedung Wettervik T, Lewén A, Enblad P. Fine tuning of neurointensive care in aneurysmal subarachnoid hemorrhage: From one-size-fits-all towards individualized care. World Neurosurg X 2023; 18:100160. [PMID: 36818739 PMCID: PMC9932216 DOI: 10.1016/j.wnsx.2023.100160] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2022] [Revised: 01/20/2023] [Accepted: 01/22/2023] [Indexed: 01/25/2023] Open
Abstract
Aneurysmal subarachnoid hemorrhage (aSAH) is a severe type of acute brain injury with high mortality and burden of neurological sequelae. General management aims at early aneurysm occlusion to prevent re-bleeding, cerebrospinal fluid drainage in case of increased intracranial pressure and/or acute hydrocephalus, and cerebral blood flow augmentation in case of delayed ischemic neurological deficits. In addition, the brain is vulnerable to physiological insults in the acute phase and neurointensive care (NIC) is important to optimize the cerebral physiology to avoid secondary brain injury. NIC has led to significantly better neurological recovery following aSAH, but there is still great room for further improvements. First, current aSAH NIC management protocols are to some extent extrapolated from those in traumatic brain injury, notwithstanding important disease-specific differences. Second, the same NIC management protocols are applied to all aSAH patients, despite great patient heterogeneity. Third, the main variables of interest, intracranial pressure and cerebral perfusion pressure, may be too superficial to fully detect and treat several important pathomechanisms. Fourth, there is a lack of understanding not only regarding physiological, but also cellular and molecular pathomechanisms and there is a need to better monitor and treat these processes. This narrative review aims to discuss current state-of-the-art NIC of aSAH, knowledge gaps in the field, and future directions towards a more individualized care in the future.
Collapse
Affiliation(s)
- Teodor Svedung Wettervik
- Corresponding author. Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden.
| | | | | |
Collapse
|
19
|
Sharma R, Tsikvadze M, Peel J, Howard L, Kapoor N, Freeman WD. Multimodal monitoring: practical recommendations (dos and don'ts) in challenging situations and uncertainty. Front Neurol 2023; 14:1135406. [PMID: 37206910 PMCID: PMC10188941 DOI: 10.3389/fneur.2023.1135406] [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: 12/31/2022] [Accepted: 04/06/2023] [Indexed: 05/21/2023] Open
Abstract
With the advancements in modern medicine, new methods are being developed to monitor patients in the intensive care unit. Different modalities evaluate different aspects of the patient's physiology and clinical status. The complexity of these modalities often restricts their use to the realm of clinical research, thereby limiting their use in the real world. Understanding their salient features and their limitations can aid physicians in interpreting the concomitant information provided by multiple modalities to make informed decisions that may affect clinical care and outcomes. Here, we present a review of the commonly used methods in the neurological intensive care unit with practical recommendations for their use.
Collapse
Affiliation(s)
- Rohan Sharma
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
- *Correspondence: Rohan Sharma
| | - Mariam Tsikvadze
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Jeffrey Peel
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Levi Howard
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| | - Nidhi Kapoor
- Department of Neurology, Baptist Medical Center, Jacksonville, FL, United States
| | - William D. Freeman
- Department of Neurology, Mayo Clinic in Florida, Jacksonville, FL, United States
| |
Collapse
|
20
|
Hawryluk GWJ, Citerio G, Hutchinson P, Kolias A, Meyfroidt G, Robba C, Stocchetti N, Chesnut R. Intracranial pressure: current perspectives on physiology and monitoring. Intensive Care Med 2022; 48:1471-1481. [PMID: 35816237 DOI: 10.1007/s00134-022-06786-y] [Citation(s) in RCA: 52] [Impact Index Per Article: 26.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/01/2022] [Accepted: 06/08/2022] [Indexed: 02/06/2023]
Abstract
Intracranial pressure (ICP) monitoring is now viewed as integral to the clinical care of many life-threatening brain insults, such as severe traumatic brain injury, subarachnoid hemorrhage, and malignant stroke. It serves to warn of expanding intracranial mass lesions, to prevent or treat herniation events as well as pressure elevation which impedes nutrient delivery to the brain. It facilitates the calculation of cerebral perfusion pressure (CPP) and the estimation of cerebrovascular autoregulatory status. Despite advancements in our knowledge emanating from a half century of experience with this technology, important controversies remain related even to fundamental aspects of ICP measurements, including indications for monitoring, ICP treatment thresholds, and management of intracranial hypertension. Here, we review the history of ICP monitoring, the underlying pathophysiology as well as current perspectives on why, when and how ICP monitoring is best used. ICP is typically assessed invasively but a number of emerging, non-invasive technologies with inherently lower risk are showing promise. In selected cases, additional neuromonitoring can be used to assist in the interpretation of ICP monitoring information and adapt directed treatment accordingly. Additional efforts to expand the evidence base relevant to ICP monitoring, related technologies and management remain a high priority in neurosurgery and neurocritical care.
Collapse
Affiliation(s)
- Gregory W J Hawryluk
- Section of Neurosurgery, University of Manitoba, GB1, 820 Sherbrook Street, Winnipeg, MB, R3A 1R9, Canada.
| | - Giuseppe Citerio
- School of Medicine and Surgery, University of Milan-Bicocca, Milan, Italy.,Neuro-Intensive Care, Department of Neurosciences, San Gerardo Hospital, ASST-MONZA, Monza, Italy
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Angelos Kolias
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB20QQ, UK
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Herestraat 49, Box 7003, 63 3000, Leuven, Belgium
| | - Chiara Robba
- Anaesthesia and Intensive Care, San Martino Research Hospital, Genoa, Italy
| | - Nino Stocchetti
- Anesthesia and Intensive Care, Department of Physiopathology and Transplantation, Milan University, Milan, Italy.,Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Randall Chesnut
- Neurosurgery, Neurotrauma, Department of Neurological Surgery, Department of Orthopaedic Surgery, School of Global Health, Harborview Medical Center, University of Washington, 325 Ninth Ave, Mailstop 359766, Seattle, WA, 98104-2499, USA
| |
Collapse
|
21
|
Lazaridis C, Ajith A, Mansour A, Okonkwo DO, Diaz-Arrastia R, Mayampurath A, Arrastia RD, Temkin N, Moore C, Shutter L, Madden C, Andaluz N, Okonkwo D, Chesnut R, Bullock R, McGregor J, Grant G, Shapiro M, Weaver M, LeRoux P, Jallo J. Prediction of Intracranial Hypertension and Brain Tissue Hypoxia Utilizing High-Resolution Data from the BOOST-II Clinical Trial. Neurotrauma Rep 2022; 3:473-478. [PMID: 36337077 PMCID: PMC9622207 DOI: 10.1089/neur.2022.0055] [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] [Indexed: 11/05/2022] Open
Abstract
The current approach to intracranial hypertension and brain tissue hypoxia is reactive, based on fixed thresholds. We used statistical machine learning on high-frequency intracranial pressure (ICP) and partial brain tissue oxygen tension (PbtO2) data obtained from the BOOST-II trial with the goal of constructing robust quantitative models to predict ICP/PbtO2 crises. We derived the following machine learning models: logistic regression (LR), elastic net, and random forest. We split the data set into 70–30% for training and testing and utilized a discrete-time survival analysis framework and 5-fold hyperparameter optimization strategy for all models. We compared model performances on discrimination between events and non-events of increased ICP or low PbtO2 with the area under the receiver operating characteristic (AUROC) curve. We further analyzed clinical utility through a decision curve analysis (DCA). When considering discrimination, the number of features, and interpretability, we identified the RF model that combined the most recent ICP reading, episode number, and longitudinal trends over the preceding 30 min as the best performing for predicting ICP crisis events within the next 30 min (AUC 0.78). For PbtO2, the LR model utilizing the most recent reading, episode number, and longitudinal trends over the preceding 30 min was the best performing (AUC, 0.84). The DCA showed clinical usefulness for wide risk of thresholds for both ICP and PbtO2 predictions. Acceptable alerting thresholds could range from 20% to 80% depending on a patient-specific assessment of the benefit-risk ratio of a given intervention in response to the alert.
Collapse
Affiliation(s)
- Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| | - Aswathy Ajith
- Department of Computer Science, University of Chicago, Chicago, Illinois, USA
| | - Ali Mansour
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, University of Chicago, Chicago, Illinois, USA
| | - David O. Okonkwo
- Department of Neurosurgery, University of Pittsburgh, Pittsburgh, Pennsylvania, USA
| | - Ramon Diaz-Arrastia
- Department of Neurology, University of Pennsylvania Perelman School of Medicine, Philadelphia, Pennsylvania, USA
| | - Anoop Mayampurath
- Department of Biostatistics and Medical Informatics, University of Wisconsin, Madison, Wisconsin, USA
| | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | | |
Collapse
|
22
|
El-Swaify ST, Kamel M, Ali SH, Bahaa B, Refaat MA, Amir A, Abdelrazek A, Beshay PW, Basha AKMM. Initial neurocritical care of severe traumatic brain injury: New paradigms and old challenges. Surg Neurol Int 2022; 13:431. [DOI: 10.25259/sni_609_2022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/08/2022] [Accepted: 08/29/2022] [Indexed: 11/04/2022] Open
Abstract
Background:
Early neurocritical care aims to ameliorate secondary traumatic brain injury (TBI) and improve neural salvage. Increased engagement of neurosurgeons in neurocritical care is warranted as daily briefings between the intensivist and the neurosurgeon are considered a quality indicator for TBI care. Hence, neurosurgeons should be aware of the latest evidence in the neurocritical care of severe TBI (sTBI).
Methods:
We conducted a narrative literature review of bibliographic databases (PubMed and Scopus) to examine recent research of sTBI.
Results:
This review has several take-away messages. The concept of critical neuroworsening and its possible causes is discussed. Static thresholds of intracranial pressure (ICP) and cerebral perfusion pressure may not be optimal for all patients. The use of dynamic cerebrovascular reactivity indices such as the pressure reactivity index can facilitate individualized treatment decisions. The use of ICP monitoring to tailor treatment of intracranial hypertension (IHT) is not routinely feasible. Different guidelines have been formulated for different scenarios. Accordingly, we propose an integrated algorithm for ICP management in sTBI patients in different resource settings. Although hyperosmolar therapy and decompressive craniectomy are standard treatments for IHT, there is a lack high-quality evidence on how to use them. A discussion of the advantages and disadvantages of invasive ICP monitoring is included in the study. Addition of beta-blocker, anti-seizure, and anticoagulant medications to standardized management protocols (SMPs) should be considered with careful patient selection.
Conclusion:
Despite consolidated research efforts in the refinement of SMPs, there are still many unanswered questions and novel research opportunities for sTBI care.
Collapse
Affiliation(s)
- Seif Tarek El-Swaify
- Department of Neurosurgery, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Menna Kamel
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Sara Hassan Ali
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | - Bassem Bahaa
- Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Abdelrahman Amir
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | | - Pavly Wagih Beshay
- School of Medicine, Faculty of Medicine, Ain Shams University, Cairo, Egypt
| | | |
Collapse
|
23
|
Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
Collapse
Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
| |
Collapse
|
24
|
Denis M, Lauzier B, Roumeliotis N, Orliaguet G, Emeriaud G, Javouhey E, Brossier D. Severe Traumatic Brain Injury in French-Speaking Pediatric Intensive Care Units: Study of Practices. J Pediatr Intensive Care 2022. [DOI: 10.1055/s-0042-1744298] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/18/2022] Open
Abstract
AbstractBest strategies for managing severe pediatric traumatic brain injury (TBI) are not established, with wide variations among professional practices. The main objective of this study was to assess compliance with updated pediatric TBI management guidelines (2019). A survey was distributed among French-speaking pediatric intensive care physicians from April 1 to June 30, 2019. The survey was based on a clinical case with a total of 70 questions that cover the 15 items of the 2019 TBI guidelines. The questions evaluated the assessment and management of TBI during the acute and intensive care phases. Of 487 e-mails sent, 78 surveys were included. Guidelines were adhered to (> 60%) for 10 of 15 items in the guidelines. Strong adherence to recent guideline changes was achieved for seizure prophylaxis with levetiracetam (n = 21/33, 64%) and partial pressure of carbon dioxide threshold (n = 52, 67%). However, management of the sodium and glucose thresholds and the role of transcranial Doppler were not consistent with the guidelines. Assessment of brain tissue oxygenation (n = 12, 16%) and autoregulation (n = 35, 45%) was not a common practice. There was strong agreement among clinicians on the intracranial pressure (> 80%) and cerebral perfusion pressure (> 70%) thresholds used according to age. Overall, stated practices for the management of TBI appear to be relatively standardized among responders. Variations persist in areas with a lack of evidence and pediatric-specific recommendations.
Collapse
Affiliation(s)
- Manon Denis
- Pediatric Intensive Care Unit, CHU de Caen, Caen, France
- Pediatric Intensive Care Unit, CHU de Nantes, Nantes, France
- Institut du thorax, INSERM, CNRS, Nantes Université, CHU de Nantes, France
- Institut du thorax, INSERM, CNRS, Nantes Université, France
| | | | - Nadia Roumeliotis
- Pediatric Intensive Care Unit, CHU Sainte Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Gilles Orliaguet
- Surgical Pediatric Intensive Care Unit, Necker–Enfants Malades University Hospital, Paris, France
- Department of Pediatric and Obstetrical Anaesthesia and Intensive Care, Necker–Enfants Malades University Hospital, GHU AP-HP Centre - Université de Paris, Paris, France
- EA08 Pharmacologie et évaluation des thérapeutiques chez l'enfant et la femme enceinte, Université de Paris, Paris, France
| | - Guillaumes Emeriaud
- Pediatric Intensive Care Unit, CHU Sainte Justine, Montréal, Quebec, Canada
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
| | - Etienne Javouhey
- Pediatric Intensive Care Unit, Hôpital Femme Mère Enfant, Hospices Civils de Lyon, Bron, France
| | - David Brossier
- Pediatric Intensive Care Unit, CHU de Caen, Caen, France
- Department of Pediatrics, Université de Montréal, Montréal, Quebec, Canada
- School of Medicine, University Caen Normandie, Caen, F-14000, France
| |
Collapse
|
25
|
Yang C, Ma Y, Xie L, Wu X, Hui J, Jiang J, Gao G, Feng J. Intracranial Pressure Monitoring in the Intensive Care Unit for Patients with Severe Traumatic Brain Injury: Analysis of the CENTER-TBI China Registry. Neurocrit Care 2022; 37:160-171. [PMID: 35246788 DOI: 10.1007/s12028-022-01463-w] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/16/2021] [Accepted: 01/31/2022] [Indexed: 12/25/2022]
Abstract
BACKGROUND Although the current guidelines recommend the use of intracranial pressure (ICP) monitoring in patients with severe traumatic brain injury (sTBI), the evidence indicating benefit is limited. The present study aims to evaluate the impact of ICP monitoring on patients with sTBI in the intensive care unit (ICU). METHODS The patient data were obtained from the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury China Registry, a prospective, multicenter, longitudinal, observational, cohort study. Patients with sTBI who were admitted to 52 ICUs across China, managed with ICP monitoring or without, were analyzed in this study. Patients with missing information on discharge survival status, Glasgow Coma Scale score on admission to hospital, and record of ICP monitoring application were excluded from the analysis. Data on demographic characteristics, injury, clinical features, treatments, survival at discharge, discharge destination, and length of stay were collected and assessed. The primary end point was survival state at discharge, and death from any cause was considered the event of interest. RESULTS A total of 2029 patients with sTBI were admitted to the ICU; 737 patients (36.32%) underwent ICP monitoring, and 1292 (63.68%) were managed without ICP monitoring. There was a difference between management with and without ICP monitoring on in-hospital mortality in the unmatched cohort (18.86% vs. 26.63%, p < 0.001) and the propensity-score-matched cohort (19.82% vs. 26.83%, p = 0.003). Multivariate logistic regressions also indicated that increasing age, higher injury severity score, lower Glasgow Coma Scale score, unilateral and bilateral pupillary abnormalities, systemic hypotension (SBP ≤ 90 mm Hg), hypoxia (SpO2 < 95%) on arrival at the hospital, and management without ICP monitoring were associated with higher in-hospital mortality. However, the patients without ICP monitoring had a lower length of stay in the ICU (11.79 vs. 7.95 days, p < 0.001) and hospital (25.96 vs. 21.71 days, p < 0.001), and a higher proportion of survivors were discharged to the home with better recovery in self-care. CONCLUSIONS Although ICP monitoring was not widely used by all of the centers participating in this study, patients with sTBI managed with ICP monitoring show a better outcome in overall survival. Nevertheless, the use of ICP monitoring makes the management of sTBI more complex and increases the costs of medical care by prolonging the patient's stay in the ICU or hospital.
Collapse
Affiliation(s)
- Chun Yang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Yuxiao Ma
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Li Xie
- Clinical Research Institute, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Xiang Wu
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Jiyuan Hui
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Jiyao Jiang
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China
- Shanghai Institute of Head Trauma, Shanghai, China
| | - Guoyi Gao
- Department of Neurosurgery, Shanghai General Hospital, Shanghai Jiao Tong University School of Medicine, Shanghai, China.
| | - Junfeng Feng
- Brain Injury Center, Department of Neurosurgery, Renji Hospital, School of Medicine, Shanghai Jiao Tong University, Shanghai, China.
- Shanghai Institute of Head Trauma, Shanghai, China.
| |
Collapse
|
26
|
Yang Y, Pan Y, Chen C, Zhao P, Hang C. Clinical Significance of Multiparameter Intracranial Pressure Monitoring in the Prognosis Prediction of Hypertensive Intracerebral Hemorrhage. J Clin Med 2022; 11:jcm11030671. [PMID: 35160123 PMCID: PMC8836722 DOI: 10.3390/jcm11030671] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2021] [Revised: 01/19/2022] [Accepted: 01/26/2022] [Indexed: 11/23/2022] Open
Abstract
Objective: The present study aimed to investigate the clinical significance of multiparameter intracranial pressure (ICP) monitoring in the prediction of the prognosis of hypertensive intracerebral hemorrhage (HICH). Methods: A retrospective analysis was performed on the clinical data of 53 HICH patients. The patients underwent removal of intracranial hemorrhage and decompressive craniectomy after admission. A ventricular ICP monitoring probe was used to continuously and invasively monitor mean arterial pressure (MAP) and ICP after surgery. The NEUMATIC system was used to collect ICP data, including pressure reactivity index (PRx), ICP dose (DICP), amplitude and pressure regression (RAP), and cerebral perfusion pressure (CPP). The mean PRx, CPP, RAP, ICP, and DICP20 mmHg × h were calculated with 1 h as the time segment. According to the Glasgow outcome scale (GOS) scores after discharge, the patients were grouped into the poor prognosis group (GOS I–III) and the good prognosis group (GOS IV and V). The two groups were compared in terms of GOS scores in the treatment and prediction of prognosis of patients. Results: The good prognosis group showed significantly lower values of mean ICP, DICP20 mmHg × h, RAP, and PRx than the poor prognosis group, while CPP was significantly higher (p < 0.001). Conclusions: PRx, DICP, RAP, and CPP could reflect intracranial changes in patients and were significantly correlated with the prognosis of the patients. Mean ICP, PRx, DICP20 mmHg × h, and RAP were negatively correlated with prognosis, while CPP was positively correlated with prognosis.
Collapse
Affiliation(s)
- Yongbo Yang
- Department of Neurosurgery, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China; (Y.Y.); (C.C.)
| | - Yuchun Pan
- Department of Neurosurgery, Nanjing Lishui People’s Hospital, Nanjing 211200, China;
| | - Chunlei Chen
- Department of Neurosurgery, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China; (Y.Y.); (C.C.)
| | - Penglai Zhao
- Department of Neurosurgery, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China; (Y.Y.); (C.C.)
- Correspondence: (P.Z.); (C.H.)
| | - Chunhua Hang
- Department of Neurosurgery, The Affiliated Nanjing Drum Tower Hospital of Nanjing University Medical School, Nanjing 210008, China; (Y.Y.); (C.C.)
- Correspondence: (P.Z.); (C.H.)
| |
Collapse
|
27
|
Zeiler FA, Iturria-Medina Y, Thelin EP, Gomez A, Shankar JJ, Ko JH, Figley CR, Wright GEB, Anderson CM. Integrative Neuroinformatics for Precision Prognostication and Personalized Therapeutics in Moderate and Severe Traumatic Brain Injury. Front Neurol 2021; 12:729184. [PMID: 34557154 PMCID: PMC8452858 DOI: 10.3389/fneur.2021.729184] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/22/2021] [Accepted: 08/09/2021] [Indexed: 01/13/2023] Open
Abstract
Despite changes in guideline-based management of moderate/severe traumatic brain injury (TBI) over the preceding decades, little impact on mortality and morbidity have been seen. This argues against the "one-treatment fits all" approach to such management strategies. With this, some preliminary advances in the area of personalized medicine in TBI care have displayed promising results. However, to continue transitioning toward individually-tailored care, we require integration of complex "-omics" data sets. The past few decades have seen dramatic increases in the volume of complex multi-modal data in moderate and severe TBI care. Such data includes serial high-fidelity multi-modal characterization of the cerebral physiome, serum/cerebrospinal fluid proteomics, admission genetic profiles, and serial advanced neuroimaging modalities. Integrating these complex and serially obtained data sets, with patient baseline demographics, treatment information and clinical outcomes over time, can be a daunting task for the treating clinician. Within this review, we highlight the current status of such multi-modal omics data sets in moderate/severe TBI, current limitations to the utilization of such data, and a potential path forward through employing integrative neuroinformatic approaches, which are applied in other neuropathologies. Such advances are positioned to facilitate the transition to precision prognostication and inform a top-down approach to the development of personalized therapeutics in moderate/severe TBI.
Collapse
Affiliation(s)
- Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB, Canada
- Centre on Aging, University of Manitoba, Winnipeg, MB, Canada
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Yasser Iturria-Medina
- Department of Neurology and Neurosurgery, Faculty of Medicine, McGill University, Montreal, QC, Canada
- McConnell Brain Imaging Centre, Montreal Neurological Institute, Montreal, QC, Canada
- Ludmer Centre for Neuroinformatics and Mental Health, Montreal, QC, Canada
| | - Eric P. Thelin
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Alwyn Gomez
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Jai J. Shankar
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Ji Hyun Ko
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Chase R. Figley
- Department of Radiology, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
| | - Galen E. B. Wright
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
- Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Chris M. Anderson
- Neuroscience Research Program, Kleysen Institute for Advanced Medicine, Winnipeg, MB, Canada
- Department of Pharmacology and Therapeutics, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| |
Collapse
|
28
|
Svedung Wettervik T, Howells T, Ljunghill Hedberg A, Lewén A, Enblad P. Intracranial pressure dynamics and cerebral vasomotor reactivity in community-acquired bacterial meningitis during neurointensive care. J Neurosurg 2021; 136:831-839. [PMID: 34388717 DOI: 10.3171/2021.2.jns2148] [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: 01/07/2021] [Accepted: 02/03/2021] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Community-acquired bacterial meningitis (CABM) is a severe condition associated with high mortality. In this study the first aim was to evaluate the incidence of intracranial pressure (ICP) insults and disturbances in cerebral vasomotor reactivity and the second aim was to evaluate the management and clinical outcome of CABM patients treated in the neurointensive care unit (NICU). METHODS CABM patients who were treated in the NICU of Uppsala University Hospital, Sweden, during 2008-2020 were included in the study. Data on demographics, admission variables, treatment, ICP dynamics, vasomotor reactivity, and short-term clinical outcome were evaluated in these patients. RESULTS Of 97 CABM patients, 81 (84%) received ICP monitoring, of whom 22% had ICP > 20 mm Hg during 5% or more of the monitoring time on day 1, which decreased to 9% on day 3. For those patients with ICP monitoring, 46% required CSF drainage, but last-tier ICP treatment, including thiopental (4%) and decompressive craniectomy (1%), was rare. Cerebral vasomotor reactivity was disturbed, with a mean pressure reactivity index (PRx) above 0.2 in 45% of the patients on day 1, and remained high for the first 3 days. In total, 81 (84%) patients had a favorable outcome (Glasgow Coma Scale motor score [GCS M] 6) at discharge, 9 (9%) patients had an unfavorable outcome (GCS M < 6) at discharge, and 7 (7%) patients died in the NICU. Those with favorable outcome had significantly better cerebral vasomotor reactivity (lower PRx) than the two other outcome groups (p < 0.01). CONCLUSIONS Intracranial hypertension was frequent following severe CABM and CSF drainage was often sufficient to control ICP. Cerebral vasomotor reactivity was commonly disturbed and associated with poor outcome. Clinical outcome was slightly better than in earlier studies.
Collapse
Affiliation(s)
| | | | - Anna Ljunghill Hedberg
- 2Department of Medical Sciences, Section of Infectious Diseases, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- 1Department of Neuroscience, Section of Neurosurgery, and
| | - Per Enblad
- 1Department of Neuroscience, Section of Neurosurgery, and
| |
Collapse
|
29
|
Appavu B, Temkit M'H, Foldes S, Burrows BT, Kuwabara M, Jacobson A, Adelson PD. Association of Outcomes with Model-Based Indices of Cerebral Autoregulation After Pediatric Traumatic Brain Injury. Neurocrit Care 2021; 35:640-650. [PMID: 34268644 DOI: 10.1007/s12028-021-01279-0] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/02/2021] [Accepted: 05/17/2021] [Indexed: 10/20/2022]
Abstract
BACKGROUND We investigated whether model-based indices of cerebral autoregulation (CA) are associated with outcomes after pediatric traumatic brain injury. METHODS This was a retrospective analysis of a prospective clinical database of 56 pediatric patients with traumatic brain injury undergoing intracranial pressure monitoring. CA indices were calculated, including pressure reactivity index (PRx), wavelet pressure reactivity index (wPRx), pulse amplitude index (PAx), and correlation coefficient between intracranial pressure pulse amplitude and cerebral perfusion pressure (RAC). Each CA index was used to compute optimal cerebral perfusion pressure (CPP). Time of CPP below lower limit of autoregulation (LLA) or above upper limit of autoregulation (ULA) were computed for each index. Demographic, physiologic, and neuroimaging data were collected. Primary outcome was determined using Pediatric Glasgow Outcome Scale Extended (GOSE-Peds) at 12 months, with higher scores being suggestive of unfavorable outcome. Univariate and multiple linear regression with guided stepwise variable selection was used to find combinations of risk factors that can best explain the variability of GOSE-Peds scores, and the best fit model was applied to the age strata. We hypothesized that higher GOSE-Peds scores were associated with higher CA values and more time below LLA or above ULA for each index. RESULTS At the univariate level, CPP, dose of intracranial hypertension, PRx, PAx, wPRx, RAC, percent time more than ULA derived for PAx, and percent time less than LLA derived for PRx, PAx, wPRx, and RAC were all associated with GOSE-Peds scores. The best subset model selection on all pediatric patients identified that when accounting for CPP, increased dose of intracranial hypertension and percent time less than LLA derived for wPRx were independently associated with higher GOSE-Peds scores. Age stratification of the best fit model identified that in children less than 2 years of age or 8 years of age or more, percent time less than LLA derived for wPRx represented the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and dose of intracranial hypertension. For children 2 years or younger to less than 8 years of age, dose of intracranial hypertension was identified as the sole independent predictor of higher GOSE-Peds scores when accounting for CPP and percent time less than LLA derived for wPRx. CONCLUSIONS Increased dose of intracranial hypertension, PRx, wPRx, PAx, and RAC values and increased percentage time less than LLA based on PRx, wPRx, PAx, and RAC are associated with higher GOSE-Peds scores, suggestive of unfavorable outcome. Reducing intracranial hypertension and maintaining CPP more than LLA based on wPRx may improve outcomes and warrants prospective investigation.
Collapse
Affiliation(s)
- Brian Appavu
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA. .,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.
| | - M 'Hamed Temkit
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Stephen Foldes
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
| | - Brian T Burrows
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - Michael Kuwabara
- Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA.,Department of Radiology, Phoenix Children's Hospital, 1919 E. Thomas Road, Phoenix, AZ, USA
| | - Austin Jacobson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA
| | - P David Adelson
- Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, 1919 E. Thomas Road, Ambulatory Building B, 4th Floor, Phoenix, AZ, USA.,Department of Child Health, University of Arizona College of Medicine, Phoenix, 550 E. Van Buren Street, Phoenix, AZ, USA
| |
Collapse
|
30
|
Sedation and cerebrovascular reactivity in traumatic brain injury: another potential avenue for personalized approaches in neurocritical care? Acta Neurochir (Wien) 2021; 163:1383-1389. [PMID: 33404872 DOI: 10.1007/s00701-020-04662-6] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/15/2020] [Accepted: 11/28/2020] [Indexed: 10/22/2022]
Abstract
BACKGROUND Impaired cerebrovascular reactivity appears to be linked to worse global outcome in adult traumatic brain injury (TBI). Literature suggests that current treatments administered in TBI care, in the intensive care unit (ICU), fail to greatly impact recorded cerebrovascular reactivity measures. In particular, the impact of sedation on cerebrovascular reactivity in traumatic brain injury (TBI) remains unclear in vivo. The goal of this study was to preliminarily assess the relationship between objectively measured depth of sedation and cerebrovascular reactivity in TBI. METHODS Within, we describe a case series of 5 adult TBI patients with TBI, during which objective high-frequency physiology for sedation depth, using bispectral index (BIS), and both intracranial pressure (ICP) and arterial blood pressure (ABP) were recorded. Pressure reactivity index (PRx) and RAP (a metric of cerebral compensatory reserve) were derived. Relationships between cerebrovascular reactivity and compensatory reserve monitoring with BIS metrics were explored using descriptive plots. RESULTS A total of 5 cases in our prospectively maintained database with high-frequency physiology for ICP, ABP, and BIS. Through error bar plotting, it can be seen that each patient displays a parabolic relationship between BIS and PRx. This suggests a potential "optimal" depth of sedation where cerebrovascular reactivity is the most intact. CONCLUSIONS This small series highlights the potential impact of depth of sedation on cerebrovascular reactivity in TBI. It suggests that there may be an individual optimal depth of sedation, so as to optimize cerebrovascular reactivity. Further study of objective depth of sedation and its impact on cerebrovascular physiology in TBI is required.
Collapse
|
31
|
Doron O, Barnea O, Stocchetti N, Or T, Nossek E, Rosenthal G. Cardiac-gated intracranial elastance in a swine model of raised intracranial pressure: a novel method to assess intracranial pressure-volume dynamics. J Neurosurg 2021; 134:1650-1657. [PMID: 32503002 DOI: 10.3171/2020.3.jns193262] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2019] [Accepted: 03/31/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Previous studies have demonstrated the importance of intracranial elastance; however, methodological difficulties have limited widespread clinical use. Measuring elastance may offer potential benefit in helping to identify patients at risk for untoward intracranial pressure (ICP) elevation from small rises in intracranial volume. The authors sought to develop an easily used method that accounts for the changing ICP that occurs over a cardiac cycle and to assess this method in a large-animal model over a broad range of ICPs. METHODS The authors used their previously described cardiac-gated intracranial balloon pump and swine model of cerebral edema. In the present experiment they measured elastance at 4 points along the cardiac cycle-early systole, peak systole, mid-diastole, and end diastole-by using rapid balloon inflation to 1 ml over an ICP range of 10-30 mm Hg. RESULTS The authors studied 7 swine with increasing cerebral edema. Intracranial elastance rose progressively with increasing ICP. Peak-systolic and end-diastolic elastance demonstrated the most consistent rise in elastance as ICP increased. Cardiac-gated elastance measurements had markedly lower variance within swine compared with non-cardiac-gated measures. The slope of the ICP-elastance curve differed between swine. At ICP between 20 and 25 mm Hg, elastance varied between 8.7 and 15.8 mm Hg/ml, indicating that ICP alone cannot accurately predict intracranial elastance. CONCLUSIONS Measuring intracranial elastance in a cardiac-gated manner is feasible and may offer an improved precision of measure. The authors' preliminary data suggest that because elastance values may vary at similar ICP levels, ICP alone may not necessarily best reflect the state of intracranial volume reserve capacity. Paired ICP-elastance measurements may offer benefit as an adjunct "early warning monitor" alerting to the risk of untoward ICP elevation in brain-injured patients that is induced by small increases in intracranial volume.
Collapse
Affiliation(s)
- Omer Doron
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Ofer Barnea
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Nino Stocchetti
- 3Department of Physiopathology and Transplantation, Milan University and Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy; and
| | - Tal Or
- 2Department of Biomedical Engineering, Tel Aviv University, Tel Aviv, Israel
| | - Erez Nossek
- 4Department of Neurosurgery, New York University Medical Center, New York, New York
| | - Guy Rosenthal
- 1Department of Neurosurgery, Hadassah-Hebrew University Medical Center, Jerusalem
| |
Collapse
|
32
|
Wellard J, Kuwabara M, Adelson PD, Appavu B. Physiologic Characteristics of Hyperosmolar Therapy After Pediatric Traumatic Brain Injury. Front Neurol 2021; 12:662089. [PMID: 33959090 PMCID: PMC8093760 DOI: 10.3389/fneur.2021.662089] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/31/2021] [Accepted: 03/24/2021] [Indexed: 11/17/2022] Open
Abstract
All work was performed at the Barrow Neurological Institute at Phoenix Children's Hospital. Objective: Investigate injury severity, neuroimaging, physiology, and outcomes with bolus hyperosmolar therapy (HT) of 3% hypertonic saline or mannitol. Methods: Retrospective cohort analysis was performed. Physiologic variables included intracranial pressure (ICP), arterial blood pressure (ABP), and heart rate (HR). Volume-pressure compensation (PVC) indices included ICP pulse amplitude (AMP) and correlation of AMP and ICP (RAP). Cerebrovascular pressure reactivity (CVPR) indices included pressure reactivity index (PRx), pulse amplitude index (PAx), wavelet PRx (wPRx), and correlation of AMP and cerebral perfusion pressure (RAC). Heart rate variability (HRV) indices included heart rate standard deviation (HRsd), heart rate root mean square of successive differences (HRrmssd) and low-high frequency ratio (LHF). Outcome was assessed using Glasgow Outcomes Scale Extended Pediatrics, 12-months post-injury. Generalized estimating equations was applied to investigate associations of physiologic changes and pre-treatment indices with HT efficacy. Repeated measures analysis of variance was applied to investigate changes after HT without intracranial hypertension (ICH). Wilcoxon rank-sum was applied to investigate HT responsiveness with age, injury severity, neuroimaging, and outcomes. Results: Thirty children received bolus HT. ICH reduction after HT was associated with reduced ICP (p = 0.0064), ABP (p = 0.0126), PRx (p = 0.0063), increased HRsd (p = 0.0408), and decreased pretreatment RAC (p = 0.0115) and wPRx (p = 0.0072). HT-responsive patients were older and had improved outcomes (p = 0.0394). HT without ICH was associated with increased ICP (P < 0.0001) and ABP (P < 0.0001), increases in all HRV indices and decreases in all PVC indices. Conclusion: After pediatric TBI, efficacious HT is associated with decreased ICP and ABP, pre-treatment indices suggesting efficient CVPR, and potentially improved outcomes.
Collapse
Affiliation(s)
- Jeffrey Wellard
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States
| | - Michael Kuwabara
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Department of Radiology, Phoenix Children's Hospital, Phoenix, AZ, United States
| | - P David Adelson
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| | - Brian Appavu
- University of Arizona College of Medicine-Phoenix, Phoenix, AZ, United States.,Department of Neurosciences, Barrow Neurological Institute at Phoenix Children's Hospital, Phoenix, AZ, United States
| |
Collapse
|
33
|
Wolf S. The State of Autoregulation. Neurocrit Care 2021; 34:5-7. [PMID: 32548809 PMCID: PMC7940286 DOI: 10.1007/s12028-020-01021-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Stefan Wolf
- Department of Neurosurgery, Charité - Universitätsmedizin Berlin, Charitéplatz 1, 10117, Berlin, Germany.
| |
Collapse
|
34
|
Lazaridis C. Cerebral Autoregulation: The Concept the Legend the Promise. Neurocrit Care 2021; 34:717-719. [PMID: 33495911 DOI: 10.1007/s12028-020-01186-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/28/2020] [Accepted: 12/31/2020] [Indexed: 11/26/2022]
Affiliation(s)
- Christos Lazaridis
- Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Ave. MC 2030, Chicago, IL, 60637, USA.
| |
Collapse
|
35
|
Åkerlund CAI, Donnelly J, Zeiler FA, Helbok R, Holst A, Cabeleira M, Güiza F, Meyfroidt G, Czosnyka M, Smielewski P, Stocchetti N, Ercole A, Nelson DW. Impact of duration and magnitude of raised intracranial pressure on outcome after severe traumatic brain injury: A CENTER-TBI high-resolution group study. PLoS One 2020; 15:e0243427. [PMID: 33315872 PMCID: PMC7735618 DOI: 10.1371/journal.pone.0243427] [Citation(s) in RCA: 30] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2020] [Accepted: 11/21/2020] [Indexed: 12/19/2022] Open
Abstract
Magnitude of intracranial pressure (ICP) elevations and their duration have been associated with worse outcomes in patients with traumatic brain injuries (TBI), however published thresholds for injury vary and uncertainty about these levels has received relatively little attention. In this study, we have analyzed high-resolution ICP monitoring data in 227 adult patients in the CENTER-TBI dataset. Our aim was to identify thresholds of ICP intensity and duration associated with worse outcome, and to evaluate the uncertainty in any such thresholds. We present ICP intensity and duration plots to visualize the relationship between ICP events and outcome. We also introduced a novel bootstrap technique to evaluate uncertainty of the equipoise line. We found that an intensity threshold of 18 ± 4 mmHg (2 standard deviations) was associated with worse outcomes in this cohort. In contrast, the uncertainty in what duration is associated with harm was larger, and safe durations were found to be population dependent. The pressure and time dose (PTD) was also calculated as area under the curve above thresholds of ICP. A relationship between PTD and mortality could be established, as well as for unfavourable outcome. This relationship remained valid for mortality but not unfavourable outcome after adjusting for IMPACT core variables and maximum therapy intensity level. Importantly, during periods of impaired autoregulation (defined as pressure reactivity index (PRx)>0.3) ICP events were associated with worse outcomes for nearly all durations and ICP levels in this cohort and there was a stronger relationship between outcome and PTD. Whilst caution should be exercised in ascribing causation in observational analyses, these results suggest intracranial hypertension is poorly tolerated in the presence of impaired autoregulation. ICP level guidelines may need to be revised in the future taking into account cerebrovascular autoregulation status considered jointly with ICP levels.
Collapse
Affiliation(s)
- Cecilia AI Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
- * E-mail:
| | - Joseph Donnelly
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - Raimund Helbok
- Department of Neurology, Neurological Intensive Care Unit, Medical University of Innsbruck, Innsbruck, Austria
| | - Anders Holst
- School of Computer Science and Communication, KTH Royal Institute of Technology, Stockholm, Sweden
| | - Manuel Cabeleira
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Fabian Güiza
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Department and Laboratory of Intensive Care Medicine, University Hospitals Leuven and KU Leuven, Leuven, Belgium
| | - Marek Czosnyka
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technolology, Warszawa, Poland
| | - Peter Smielewski
- Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Department of Pathophysiology and Transplants, University of Milan, and Neuroscience Intensive Care Unit, Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, United Kingdom
| | - David W. Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | | |
Collapse
|
36
|
Escamilla-Ocañas CE, Albores-Ibarra N. Current status and outlook for the management of intracranial hypertension after traumatic brain injury: decompressive craniectomy, therapeutic hypothermia, and barbiturates. Neurologia 2020; 38:S0213-4853(20)30274-7. [PMID: 33069447 DOI: 10.1016/j.nrl.2020.08.007] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/17/2020] [Revised: 07/20/2020] [Accepted: 08/04/2020] [Indexed: 12/22/2022] Open
Abstract
INTRODUCTION Increased intracranial pressure has been associated with poor neurological outcomes and increased mortality in patients with severe traumatic brain injury. Traditionally, intracranial pressure-lowering therapies are administered using an escalating approach, with more aggressive options reserved for patients showing no response to first-tier interventions, or with refractory intracranial hypertension. DEVELOPMENT The therapeutic value and the appropriate timing for the use of rescue treatments for intracranial hypertension have been a subject of constant debate in literature. In this review, we discuss the main management options for refractory intracranial hypertension after severe traumatic brain injury in adults. We intend to conduct an in-depth revision of the most representative randomised controlled trials on the different rescue treatments, including decompressive craniectomy, therapeutic hypothermia, and barbiturates. We also discuss future perspectives for these management options. CONCLUSIONS The available evidence appears to show that mortality can be reduced when rescue interventions are used as last-tier therapy; however, this benefit comes at the cost of severe disability. The decision of whether to perform these interventions should always be patient-centred and made on an individual basis. The development and integration of different physiological variables through multimodality monitoring is of the utmost importance to provide more robust prognostic information to patients facing these challenging decisions.
Collapse
Affiliation(s)
- C E Escamilla-Ocañas
- Department of Neurology, Division of Vascular Neurology and Neurocritical Care, Baylor College of Medicine, Houston, TX, EE. UU..
| | - N Albores-Ibarra
- División de Ciencias de la Salud, Universidad de Monterrey, San Pedro Garza García, Nuevo León, México
| |
Collapse
|
37
|
Froese L, Dian J, Gomez A, Unger B, Zeiler FA. The cerebrovascular response to norepinephrine: A scoping systematic review of the animal and human literature. Pharmacol Res Perspect 2020; 8:e00655. [PMID: 32965778 PMCID: PMC7510331 DOI: 10.1002/prp2.655] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2020] [Revised: 08/14/2020] [Accepted: 08/20/2020] [Indexed: 12/12/2022] Open
Abstract
Intravenous norepinephrine (NE) is utilized commonly in critical care for cardiovascular support. NE's impact on cerebrovasculature is unclear and may carry important implications during states of critical neurological illness. The aim of the study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of NE. A search of MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019 was performed. All manuscripts pertaining to the administration of NE, in which the impact on CBF/cerebral vasculature was recorded, were included. We identified 62 animal studies and 26 human studies. Overall, there was a trend to a direct vasoconstriction effect of NE on the cerebral vasculature, with conflicting studies having demonstrated both increases and decreases in regional CBF (rCBF) or global CBF. Healthy animals and those undergoing cardiopulmonary resuscitation demonstrated a dose-dependent increase in CBF with NE administration. However, animal models and human patients with acquired brain injury had varied responses in CBF to NE administration. The animal models indicate an increase in cerebral vasoconstriction with NE administration through the alpha receptors in vessels. Global and rCBF during the injection of NE displays a wide variation depending on treatment and model/patient.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
| | - Joshua Dian
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Alwyn Gomez
- Section of NeurosurgeryDepartment of SurgeryRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Bertram Unger
- Section of Critical CareDepartment of MedicineRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
| | - Frederick A. Zeiler
- Biomedical EngineeringFaculty of EngineeringUniversity of ManitobaWinnipegCanada
- Department of Anatomy and Cell ScienceRady Faculty of Health SciencesUniversity of ManitobaWinnipegCanada
- Centre on AgingUniversity of ManitobaWinnipegCanada
- Division of AnaesthesiaDepartment of MedicineAddenbrooke’s HospitalUniversity of CambridgeCambridgeUK
| |
Collapse
|
38
|
Zeiler FA, Beqiri E, Cabeleira M, Hutchinson PJ, Stocchetti N, Menon DK, Czosnyka M, Smielewski P, Ercole A. Brain Tissue Oxygen and Cerebrovascular Reactivity in Traumatic Brain Injury: A Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury Exploratory Analysis of Insult Burden. J Neurotrauma 2020; 37:1854-1863. [PMID: 32253987 PMCID: PMC7484893 DOI: 10.1089/neu.2020.7024] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022] Open
Abstract
Pressure reactivity index (PRx) and brain tissue oxygen (PbtO2) are associated with outcome in traumatic brain injury (TBI). This study explores the relationship between PRx and PbtO2 in adult moderate/severe TBI. Using the Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) high resolution intensive care unit (ICU) sub-study cohort, we evaluated those patients with archived high-frequency digital intraparenchymal intracranial pressure (ICP) and PbtO2 monitoring data of, a minimum of 6 h in duration, and the presence of a 6 month Glasgow Outcome Scale -Extended (GOSE) score. Digital physiological signals were processed for ICP, PbtO2, and PRx, with the % time above/below defined thresholds determined. The duration of ICP, PbtO2, and PRx derangements was characterized. Associations with dichotomized 6-month GOSE (alive/dead, and favorable/unfavorable outcome; ≤ 4 = unfavorable), were assessed. A total of 43 patients were included. Severely impaired cerebrovascular reactivity was seen during elevated ICP and low PbtO2 episodes. However, most of the acute ICU physiological derangements were impaired cerebrovascular reactivity, not ICP elevations or low PbtO2 episodes. Low PbtO2 without PRx impairment was rarely seen. % time spent above PRx threshold was associated with mortality at 6 months for thresholds of 0 (area under the curve [AUC] 0.734, p = 0.003), > +0.25 (AUC 0.747, p = 0.002) and > +0.35 (AUC 0.745, p = 0.002). Similar relationships were not seen for % time with ICP >20 mm Hg, and PbtO2 < 20 mm Hg in this cohort. Extreme impairment in cerebrovascular reactivity is seen during concurrent episodes of elevated ICP and low PbtO2. However, the majority of the deranged cerebral physiology seen during the acute ICU phase is impairment in cerebrovascular reactivity, with most impairment occurring in the presence of normal PbtO2 levels. Measures of cerebrovascular reactivity appear to display the most consistent associations with global outcome in TBI, compared with ICP and PbtO2.
Collapse
Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- 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
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Centre on Aging, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Manuel Cabeleira
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J. Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Ari Ercole
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| |
Collapse
|
39
|
Dai H, Jia X, Pahren L, Lee J, Foreman B. Intracranial Pressure Monitoring Signals After Traumatic Brain Injury: A Narrative Overview and Conceptual Data Science Framework. Front Neurol 2020; 11:959. [PMID: 33013638 PMCID: PMC7496370 DOI: 10.3389/fneur.2020.00959] [Citation(s) in RCA: 13] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/23/2019] [Accepted: 07/24/2020] [Indexed: 12/29/2022] Open
Abstract
Continuous intracranial pressure (ICP) monitoring is a cornerstone of neurocritical care after severe brain injuries such as traumatic brain injury and acts as a biomarker of secondary brain injury. With the rapid development of artificial intelligent (AI) approaches to data analysis, the acquisition, storage, real-time analysis, and interpretation of physiological signal data can bring insights to the field of neurocritical care bioinformatics. We review the existing literature on the quantification and analysis of the ICP waveform and present an integrated framework to incorporate signal processing tools, advanced statistical methods, and machine learning techniques in order to comprehensively understand the ICP signal and its clinical importance. Our goals were to identify the strengths and pitfalls of existing methods for data cleaning, information extraction, and application. In particular, we describe the use of ICP signal analytics to detect intracranial hypertension and to predict both short-term intracranial hypertension and long-term clinical outcome. We provide a well-organized roadmap for future researchers based on existing literature and a computational approach to clinically-relevant biomedical signal data.
Collapse
Affiliation(s)
- Honghao Dai
- Department of Mechanical and Materials Engineering, College of Engineering and Applied Sciences, Cincinnati, OH, United States
- NSF I/UCRC Center for Intelligent Maintenance Systems, Cincinnati, OH, United States
| | - Xiaodong Jia
- Department of Mechanical and Materials Engineering, College of Engineering and Applied Sciences, Cincinnati, OH, United States
- NSF I/UCRC Center for Intelligent Maintenance Systems, Cincinnati, OH, United States
| | - Laura Pahren
- Department of Mechanical and Materials Engineering, College of Engineering and Applied Sciences, Cincinnati, OH, United States
- NSF I/UCRC Center for Intelligent Maintenance Systems, Cincinnati, OH, United States
| | - Jay Lee
- Department of Mechanical and Materials Engineering, College of Engineering and Applied Sciences, Cincinnati, OH, United States
- NSF I/UCRC Center for Intelligent Maintenance Systems, Cincinnati, OH, United States
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, University of Cincinnati College of Medicine, University of Cincinnati Gardner Neuroscience Institute, Cincinnati, OH, United States
| |
Collapse
|
40
|
Lilja-Cyron A, Andresen M, Kelsen J, Andreasen TH, Fugleholm K, Juhler M. Long-Term Effect of Decompressive Craniectomy on Intracranial Pressure and Possible Implications for Intracranial Fluid Movements. Neurosurgery 2020; 86:231-240. [PMID: 30768137 DOI: 10.1093/neuros/nyz049] [Citation(s) in RCA: 20] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/10/2018] [Accepted: 01/29/2019] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND Decompressive craniectomy (DC) is used in cases of severe intracranial hypertension or impending intracranial herniation. DC effectively lowers intracranial pressure (ICP) but carries a risk of severe complications related to abnormal ICP and/or cerebrospinal fluid (CSF) circulation, eg, hygroma formation, hydrocephalus, and "syndrome of the trephined." OBJECTIVE To study the long-term effect of DC on ICP, postural ICP regulation, and intracranial pulse wave amplitude (PWA). METHODS Prospective observational study including patients undergoing DC during a 12-mo period. Telemetric ICP sensors (Neurovent-P-tel; Raumedic, Helmbrechts, Germany) were implanted in all patients. Following discharge from the neuro intensive care unit (NICU), scheduled weekly ICP monitoring sessions were performed during the rehabilitation phase. RESULTS A total of 16 patients (traumatic brain injury: 7, stroke: 9) were included (median age: 55 yr, range: 19-71 yr). Median time from NICU discharge to cranioplasty was 48 d (range: 16-98 d) and during this period, mean ICP gradually decreased from 7.8 ± 2.0 mm Hg to -1.8 ± 3.3 mm Hg (P = .02). The most pronounced decrease occurred during the first month. Normal postural ICP change was abolished after DC for the entire follow-up period, ie, there was no difference between ICP in supine and sitting position (P = .67). PWA was markedly reduced and decreased from initially 1.2 ± 0.7 mm Hg to 0.4 ± 0.3 mm Hg (P = .05). CONCLUSION Following NICU discharge, ICP decreases to negative values within 4 wk, normal postural ICP regulation is lost and intracranial PWA is diminished significantly. These abnormalities might have implications for intracranial fluid movements (eg, CSF and/or glymphatic flow) following DC and warrants further investigations.
Collapse
Affiliation(s)
| | - Morten Andresen
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Jesper Kelsen
- Department of Orthopedic Surgery (Spine Section), Rigshospitalet, Copenhagen, Denmark
| | | | - Kåre Fugleholm
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| | - Marianne Juhler
- Department of Neurosurgery, Rigshospitalet, Copenhagen, Denmark
| |
Collapse
|
41
|
Lazaridis C, Goldenberg FD. Intracranial Pressure in Traumatic Brain Injury: From Thresholds to Heuristics. Crit Care Med 2020; 48:1210-1213. [PMID: 32697493 DOI: 10.1097/ccm.0000000000004383] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, IL
- Division of Neurocritical Care, Department of Surgery (Neurosurgery), University of Chicago Medical Center, Chicago, IL
| | - Fernando D Goldenberg
- Division of Neurocritical Care, Department of Neurology, University of Chicago Medical Center, Chicago, IL
- Division of Neurocritical Care, Department of Surgery (Neurosurgery), University of Chicago Medical Center, Chicago, IL
| |
Collapse
|
42
|
Pan Y, Xue Y, Zhao P, Ding J, Ren Z, Xu J. Significance of ICP-related parameters for the treatment and outcome of severe traumatic brain injury. J Int Med Res 2020; 48:300060520941291. [PMID: 32854551 PMCID: PMC7459188 DOI: 10.1177/0300060520941291] [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] [Indexed: 12/22/2022] Open
Abstract
Objective To analyze the significance of intracranial pressure (ICP)-related parameters
on outcome in patients with severe traumatic brain injury. The ICP-related
parameters included ICP, ICP dose (DICP), regression of the correlation
coefficient between amplitude and pressure (RAP), pressure reactivity index
(PRx), and cerebral perfusion pressure (CPP). Methods A retrospective analysis was performed using clinical information from 29
patients with severe traumatic brain injury who were admitted to the
Department of Neurosurgery from January 2018 to January 2019. All patients
underwent ICP probe implantation after admission. Patients were followed up
for 6 months after discharge, and were categorized into either the favorable
or unfavorable outcome group based on their Glasgow Outcome Scale score. The
differences in ICP, DICP, RAP, PRx, and CPP between the two groups were
analyzed for their effects on outcome. Results The average ICP, DICP, PRx, and RAP values in patients with favorable
outcomes were significantly lower than in patients with unfavorable
outcomes, while CPP values were significantly higher in the favorable
outcome group. Conclusion Average ICP, DICP, PRx, RAP, and CPP values may indicate disease status and
relate to patient outcomes. It is important to use multiple parameters to
predict patients’ disease severity and prognosis.
Collapse
Affiliation(s)
- Yuchun Pan
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Yuanfeng Xue
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Penglai Zhao
- Department of Neurosurgery, Brain Hospital Affiliated to Nanjing Medical University, Nanjing, China
| | - Junhong Ding
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Zhiwen Ren
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| | - Jian Xu
- Department of Neurosurgery, Lishui People's Hospital, Lishui Region of Zhongda Hospital Affiliated to Southeast University, Nanjing, China
| |
Collapse
|
43
|
Froese L, Dian J, Gomez A, Unger B, Zeiler FA. Cerebrovascular Response to Phenylephrine in Traumatic Brain Injury: A Scoping Systematic Review of the Human and Animal Literature. Neurotrauma Rep 2020; 1:46-62. [PMID: 34223530 PMCID: PMC8240891 DOI: 10.1089/neur.2020.0008] [Citation(s) in RCA: 12] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022] Open
Abstract
Intravenous phenylephrine (PE) is utilized commonly in critical care for cardiovascular support. Its impact on the cerebrovasculature is unclear and its use may have important implications during states of critical neurological illness. The aim of this study was to perform a scoping review of the literature on the cerebrovascular/cerebral blood flow (CBF) effects of PE in traumatic brain injury (TBI), evaluating both animal models and human studies. We searched MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and the Cochrane Library from inception to January 2020. We identified 12 studies with various animal models and 4 studies in humans with varying TBI pathology. There was a trend toward a consistent increase in mean arterial pressure (MAP) by the injection of PE systemically, and by proxy, an increase of the cerebral perfusion pressure (CPP). There was a consistent constriction of cerebral vessels by PE reported in the small number of studies documenting such a response. However, the heterogeneity of the literature on the CBF/cerebral blood volume (CBV) response makes the strength of the conclusions on PE limited. Studies were heterogeneous in design and had significant limitations, with most failing to adjust for confounding factors in cerebrovascular/CBF response. This review highlights the significant knowledge gap on the cerebrovascular/CBF effects of PE administration in TBI, calling for further study on the impact of PE on the cerebrovasculature both in vivo and in experimental settings.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Joshua Dian
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Alwyn Gomez
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Bertram Unger
- Department of Internal Medicine, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Frederick A. Zeiler
- Biomedical Engineering, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Surgery, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Center on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anesthesia, University of Cambridge, Addenbrooke's Hospital, Cambridge, United Kingdom
| |
Collapse
|
44
|
Hasen M, Gomez A, Froese L, Dian J, Raj R, Thelin EP, Zeiler FA. Alternative continuous intracranial pressure-derived cerebrovascular reactivity metrics in traumatic brain injury: a scoping overview. Acta Neurochir (Wien) 2020; 162:1647-1662. [PMID: 32385635 DOI: 10.1007/s00701-020-04378-7] [Citation(s) in RCA: 17] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/20/2020] [Accepted: 04/25/2020] [Indexed: 12/20/2022]
Abstract
BACKGROUND Pressure reactivity index (PRx) has emerged as a means to continuously monitor cerebrovascular reactivity in traumatic brain injury (TBI). However, other intracranial pressure (ICP)-based continuous metrics exist, and may have advantages over PRx. The goal of this study was to perform a scoping overview of the literature on non-PRx ICP-based continuous cerebrovascular reactivity metrics in adult TBI. METHODS We searched MEDLINE, BIOSIS, EMBASE, Global Health, SCOPUS, and Cochrane Library from inception to December 2019. Using a two-stage filtering of title/abstract, and then full manuscript, we identified pertinent articles. Data was abstracted to tables and each technique summarized, including pulse amplitude index (PAx), correlation between pulse amplitude of ICP and cerebral perfusion pressure (RAC), PRx55-15, and low-resolution metrics LAx and L-PRx. RESULTS A total of 23 articles met the inclusion criteria, with the vast majority being retrospective in nature and based out of European centers. Sixteen articles focused on high-resolution metrics PAx, RAC, and PRx55-15, with 6 articles focusing on LAx and L-PRx. PAx may have a role in low ICP situations, where it appears to perform superior to PRx. RAC displays similar behavior to PRx, with a trend to stronger associations with favorable/unfavorable outcome at 6 months, and stronger parabolic relationship with CPP. PRx55-15 provides a focused assessment on the vasogenic frequency range associated with cerebral autoregulation, with preliminary data supporting a strong association with outcome in TBI. LAx and L-PRx display varying associations with 6-month outcome in TBI, depending on the window length of calculation, with shorter windows demonstrating stronger correlations with classical PRx. CONCLUSIONS Non-PRx continuous ICP-based cerebrovascular reactivity metrics can be split into high-resolution and low-resolution measures. High-resolution indices include PAx, RAC, and PRx55-15, while low-resolution indices include L-PRx and LAx. The true role for these metrics beyond classic PRx remains unclear. Each displays situations where it may prove superior over PRx, given limitations with this currently widely accepted measure. Much future investigation into each of these alternative metrics is required prior to adoption into the clinical monitoring armamentarium in adult TBI.
Collapse
Affiliation(s)
- Mohammed Hasen
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
- Department of Neurosurgery, King Fahad University Hospital, Imam Abdulrahman Bin Faisal University, Dammam, Saudi Arabia
| | - Alwyn Gomez
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Joshua Dian
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Rahul Raj
- Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Eric P Thelin
- Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
- Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Frederick A Zeiler
- Section of Neurosurgery, Division of Surgery, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada.
- Centre on Aging, University of Manitoba, Winnipeg, Canada.
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada.
- Department of Medicine, Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| |
Collapse
|
45
|
Precision Medicine in Acute Brain Injury: A Narrative Review. J Neurosurg Anesthesiol 2020; 34:e14-e23. [PMID: 32590476 DOI: 10.1097/ana.0000000000000710] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2020] [Accepted: 05/24/2020] [Indexed: 11/26/2022]
Abstract
Over the past few years, the concept of personalized medicine has percolated into the management of different neurological conditions. Improving outcomes after acute brain injury (ABI) continues to be a major challenge. Unrecognized individual multiomic variations in addition to multiple interacting processes may explain why we fail to observe comprehensive improvements in ABI outcomes even when applied treatments appear to be beneficial logically. The provision of clinical care based on a multiomic approach may revolutionize the management of traumatic brain injury, delayed cerebral ischemia after subarachnoid hemorrhage, acute ischemic stroke, and several other neurological diseases. The challenge is to incorporate all the information obtained from genomic studies, other omic data, and individual variability into a practical tool that can be used to assist clinical decision-making. The effective execution of such strategies, which is still far away, requires the development of protocols on the basis of these complex interactions and strict adherence to management protocols. In this review, we will discuss various omics and physiological targets to guide individualized patient management after ABI.
Collapse
|
46
|
Froese L, Batson C, Gomez A, Dian J, Zeiler FA. The Limited Impact of Current Therapeutic Interventions on Cerebrovascular Reactivity in Traumatic Brain Injury: A Narrative Overview. Neurocrit Care 2020; 34:325-335. [PMID: 32468328 DOI: 10.1007/s12028-020-01003-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Current intensive care unit (ICU) treatment strategies for traumatic brain injury (TBI) care focus on intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-directed therapeutics, dictated by guidelines. Impaired cerebrovascular reactivity in moderate/severe TBI is emerging as a major associate with poor outcome and appears to dominate the landscape of physiologic derangement over the course of a patient's ICU stay. Within this article, we review the literature on the known drivers of impaired cerebrovascular reactivity in adult TBI, highlight the current knowledge surrounding the impact of guideline treatment strategies on continuously monitored cerebrovascular reactivity, and discuss current treatment paradigms for impaired reactivity. Finally, we touch on the areas of future research, as we strive to develop specific therapeutics for impaired cerebrovascular reactivity in TBI. There exists limited literature to suggest advanced age, intracranial injury patterns of diffuse injury, and sustained ICP elevations may drive impaired cerebrovascular reactivity. To date, the literature suggests there is a limited impact of such ICP/CPP guideline-based therapies on cerebrovascular reactivity, with large portions of a given patients ICU period spent with impaired cerebrovascular reactivity. Emerging treatment paradigms focus on the targeting individualized CPP and ICP thresholds based on cerebrovascular reactivity, without directly targeting the pathways involved in its dysfunction. Further work involved in uncovering the molecular pathways involved in impaired cerebrovascular reactivity is required, so that we can develop therapeutics directed at its prevention and treatment.
Collapse
Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Josh Dian
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Centre on Aging, University of Manitoba, Winnipeg, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
| |
Collapse
|
47
|
Intracranial Pressure Threshold Heuristics in Traumatic Brain Injury: One, None, Many! Neurocrit Care 2020; 32:672-676. [DOI: 10.1007/s12028-020-00940-4] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022]
|
48
|
Guan H, Zhang C, Chen T, Zhu J, Yang S, Shu L, Shen W, Wang Y. Controlled Decompression Attenuates Brain Injury in a Novel Rabbit Model of Acute Intracranial Hypertension. Med Sci Monit 2019; 25:9776-9785. [PMID: 31859264 PMCID: PMC6933874 DOI: 10.12659/msm.919796] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022] Open
Abstract
Background In the past, standard rapid decompressive craniectomy was used to alleviate the secondary damage caused by high intracranial pressure. Recent clinical studies showed that controlled decompression may have a better curative effect than rapid decompression. However, the effect on controlled decompression in animals is unclear. Material/Methods Totally 80 healthy male New Zealand rabbits were randomly divided into a sham group (n=20), a rapid decompression group (n=30), and a controlled decompression group (n=30). An intracranial hypertension model was induced by injecting saline into an epidural balloon catheter and reducing ICP slowly and gradually by use of a pressure pump. The model was evaluated and analyzed by general observations, imaging examination, ICP values, behavioral score, brain water content, Nissl staining, and caspase-3 protein detection. Results The mortality rate was 36.7% (11/30) in the rapid group, 20% (6/30) in the controlled group, and 5% (1/20) in the sham group. The incidence of epidural hematoma in the controlled group was lower than in the rapid group (p<0.01). The ICP was significantly lower in the controlled group than in the rapid group (p<0.001), and the behavioral score in the rapid group was higher than in the controlled group (p<0.05). There was a marked difference in brain water content between the controlled group and the rapid group (p<0.01). Nissl staining demonstrated that the ratio of Nissl body in the controlled group was significantly higher than in the rapid group (p<0.01). WB detection showed the expression of Caspase-3 in the controlled group was lower than in the rapid group (p<0.05). Conclusions The results show the advantages of use of controlled decompression with intracranial hypertension. The animal model we developed provides a platform for further research on controlled decompression.
Collapse
Affiliation(s)
- Haoxiang Guan
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Can Zhang
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Tao Chen
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Jie Zhu
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Shuo Yang
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Longfei Shu
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Wei Shen
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| | - Yuhai Wang
- Department of Neurosurgery, 904TH Hospital of People's Liberation Army (PLA), Wuxi Clinical College of Anhui Medical University, Wuxi, Jiangsu, China (mainland)
| |
Collapse
|
49
|
Kim LH, Quon JL, Sun FW, Wortman KM, Adamson MM, Harris OA. Traumatic brain injury among female veterans: a review of sex differences in military neurosurgery. Neurosurg Focus 2019; 45:E16. [PMID: 30544324 DOI: 10.3171/2018.9.focus18369] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/01/2018] [Accepted: 09/10/2018] [Indexed: 11/06/2022]
Abstract
The impact of traumatic brain injury (TBI) has been demonstrated in various studies with respect to prevalence, morbidity, and mortality data. Many of the patients burdened with long-term sequelae of TBI are veterans. Although fewer in number, female veterans with TBI have been suggested to suffer from unique physical, mental, and social challenges. However, there remains a significant knowledge gap in the sex differences in TBI. Increased female representation in the military heralds an increased risk of TBI for female soldiers, and medical professionals must be prepared to address the unique health challenges in the face of changing demographics among the veteran TBI population. In this review, the authors aimed to present the current understanding of sex differences in TBI in the veteran population and suggest directions for future investigations.
Collapse
Affiliation(s)
- Lily H Kim
- 1The Defense and Veterans Brain Injury Center, VA Palo Alto Health Care System, Palo Alto.,2Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Jennifer L Quon
- 2Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Felicia W Sun
- 1The Defense and Veterans Brain Injury Center, VA Palo Alto Health Care System, Palo Alto.,3College of Medicine, University of Illinois, Chicago, Illinois
| | - Kristen M Wortman
- 1The Defense and Veterans Brain Injury Center, VA Palo Alto Health Care System, Palo Alto
| | - Maheen M Adamson
- 1The Defense and Veterans Brain Injury Center, VA Palo Alto Health Care System, Palo Alto.,2Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| | - Odette A Harris
- 1The Defense and Veterans Brain Injury Center, VA Palo Alto Health Care System, Palo Alto.,2Department of Neurosurgery, Stanford University School of Medicine, Stanford, California; and
| |
Collapse
|
50
|
Estimation of pulsatile cerebral arterial blood volume based on transcranial doppler signals. Med Eng Phys 2019; 74:23-32. [DOI: 10.1016/j.medengphy.2019.07.019] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/09/2019] [Revised: 06/30/2019] [Accepted: 07/28/2019] [Indexed: 11/20/2022]
|