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Fotakopoulos G, Siasios I, Gatos C, Georgakopoulou VE, Trakas N, Sklapani P, Fountas KN. Acute intracranial hemorrhage during the installation of the LICOX microdialysis system: A case report. MEDICINE INTERNATIONAL 2024; 4:39. [PMID: 38827950 PMCID: PMC11140294 DOI: 10.3892/mi.2024.163] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 03/13/2024] [Accepted: 05/02/2024] [Indexed: 06/05/2024]
Abstract
Neuro-monitoring is widely employed for the evaluation of intubated patients in the intensive care unit with stroke, severe head trauma, subarachnoid hemorrhage and/or hepatic encephalopathy. The present study reports the case of a patient with acute intracranial hemorrhage following the insertion of neuromonitoring catheters, which required surgical management. The patient was a 14-year-old male who sustained a severe traumatic brain injury and underwent a right-sided hemicraniectomy. During the installation of the neuromonitoring catheters, an acute hemorrhage was noted with a rapidly elevating intracranial pressure. A craniotomy was performed to identify and coagulate the injured cortical vessel. As demonstrated herein, the thorough evaluation of the clotting profile of the patient, a meticulous surgical technique and obtaining a post-insertion computed tomography scan may minimize the risk of any neuromonitoring-associated hemorrhagic complications.
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Affiliation(s)
- George Fotakopoulos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | - Ioannis Siasios
- Department of Neurosurgery, Papageorgiou Hospital, 56429 Thessaloniki, Greece
| | - Charalampos Gatos
- Department of Neurosurgery, General University Hospital of Larissa, 41221 Larissa, Greece
| | | | - Nikolaos Trakas
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
| | - Pagona Sklapani
- Department of Biochemistry, Sismanogleio Hospital, 15126 Athens, Greece
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Moncur EM, Craven CL, Al-Ahmad S, Jones B, Robertson F, Reddy U, Toma AK. Chemical angioplasty vs. balloon plus chemical angioplasty for delayed cerebral ischemia: a pilot study of PbtO 2 outcomes. Acta Neurochir (Wien) 2024; 166:179. [PMID: 38627273 PMCID: PMC11021294 DOI: 10.1007/s00701-024-06066-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/31/2023] [Accepted: 03/29/2024] [Indexed: 04/19/2024]
Abstract
BACKGROUND Delayed cerebral ischaemia (DCI) is a major cause of morbidity and mortality after aneurysmal subarachnoid haemorrhage (aSAH). Chemical angioplasty (CA) and transluminal balloon angioplasty (TBA) are used to treat patients with refractory vasospasm causing DCI. Multi-modal monitoring including brain tissue oxygenation (PbtO2) is routinely used at this centre for early detection and management of DCI following aSAH. In this single-centre pilot study, we are comparing these two treatment modalities and their effects on PbtO2. METHODS Retrospective case series of patients with DCI who had PbtO2 monitoring as part of their multimodality monitoring and underwent either CA or TBA combined with CA. PbtO2 values were recorded from intra-parenchymal Raumedic NEUROVENT-PTO® probes. Data were continuously collected and downloaded as second-by-second data. Comparisons were made between pre-angioplasty PbtO2 and post-angioplasty PbtO2 median values (4 h before angioplasty, 4 h after and 12 h after). RESULTS There were immediate significant improvements in PbtO2 at the start of intervention in both groups. PbtO2 then increased by 13 mmHg in the CA group and 15 mmHg in the TBA plus CA group in the first 4 h post-intervention. This improvement in PbtO2 was sustained for the TBA plus CA group but not the CA group. CONCLUSION Combined balloon plus chemical angioplasty results in more sustained improvement in brain tissue oxygenation compared with chemical angioplasty alone. Our findings suggest that PbtO2 is a useful tool for monitoring the response to angioplasty in vasospasm.
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Affiliation(s)
- Eleanor M Moncur
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK.
- Department of Brain Repair and Rehabilitation, UCL Queen Square Institute of Neurology, London, UK.
| | - Claudia L Craven
- Department of Neurosurgery, Cambridge University Hospitals NHS Foundation Trust, Hills Road, Cambridge, CB2 0QQ, UK
| | - Selma Al-Ahmad
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Bethany Jones
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Fergus Robertson
- Lysholm Department of Neuroradiology, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ugan Reddy
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
| | - Ahmed K Toma
- Victor Horsley Department of Neurosurgery, National Hospital for Neurology and Neurosurgery, Queen Square, London, WC1N 3BG, UK
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Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [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: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
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Brain Oxygen-Directed Management of Aneurysmal Subarachnoid Hemorrhage. Temporal Patterns of Cerebral Ischemia During Acute Brain Attack, Early Brain Injury, and Territorial Sonographic Vasospasm. World Neurosurg 2022; 166:e215-e236. [PMID: 35803565 DOI: 10.1016/j.wneu.2022.06.149] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2022] [Revised: 06/28/2022] [Accepted: 06/29/2022] [Indexed: 12/15/2022]
Abstract
BACKGROUND Neurocritical management of aneurysmal subarachnoid hemorrhage focuses on delayed cerebral ischemia (DCI) after aneurysm repair. METHODS This study conceptualizes the pathophysiology of cerebral ischemia and its management using a brain oxygen-directed protocol (intracranial pressure [ICP] control, eubaric hyperoxia, hemodynamic therapy, arterial vasodilation, and neuroprotection) in patients with subarachnoid hemorrhage, undergoing aneurysm clipping (n = 40). RESULTS The brain oxygen-directed protocol reduced Lbo2 (Pbto2 [partial pressure of brain tissue oxygen] <20 mm Hg) from 67% to 15% during acute brain attack (<24 hours of ictus), by increasing Pbto2 from 11.31 ± 9.34 to 27.85 ± 6.76 (P < 0.0001) and then to 29.09 ± 17.88 within 72 hours. Day-after-bleed, Fio2 change, ICP, hemoglobin, and oxygen saturation were predictors for Pbto2 during early brain injury. Transcranial Doppler ultrasonography velocities (>20 cm/second) increased at day 2. During DCI caused by territorial sonographic vasospasm (TSV), middle cerebral artery mean velocity (Vm) increased from 45.00 ± 15.12 to 80.37 ± 38.33/second by day 4 with concomitant Pbto2 reduction from 29.09 ± 17.88 to 22.66 ± 8.19. Peak TSV (days 7-12) coincided with decline in Pbto2. Nicardipine mitigated Lbo2 during peak TSV, in contrast to nimodipine, with survival benefit (P < 0.01). Intravenous and cisternal nicardipine combination had survival benefit (Cramer Φ = 0.43 and 0.327; G2 = 28.32; P < 0.001). This study identifies 4 zones of Lbo2 during survival benefit (Cramer Φ = 0.43 and 0.3) TSV, uncompensated; global cerebral ischemia, compensated, and normal Pbto2. Admission Glasgow Coma Scale score (not increased ICP) was predictive of low Pbto2 (β = 0.812, R2 = 0.661, F1,30 = 58.41; P < 0.0001) during early brain injury. Coma was the only credible predictor for mortality (odds ratio, 7.33/>4.8∗; χ2 = 7.556; confidence interval, 1.70-31.54; P < 0.01) followed by basilar aneurysm, poor grade, high ICP and Lbo2 during TSV. Global cerebral ischemia occurs immediately after the ictus, persisting in 30% of patients despite the high therapeutic intensity level, superimposed by DCI during TSV. CONCLUSIONS We propose implications for clinical practice and patient management to minimize cerebral ischemia.
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Hosmann A, Wang WT, Dodier P, Bavinzski G, Engel A, Herta J, Plöchl W, Reinprecht A, Gruber A. The Impact of Intra-Arterial Papaverine-Hydrochloride on Cerebral Metabolism and Oxygenation for Treatment of Delayed-Onset Post-Subarachnoid Hemorrhage Vasospasm. Neurosurgery 2021; 87:712-719. [PMID: 31792510 DOI: 10.1093/neuros/nyz500] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/21/2019] [Accepted: 09/04/2019] [Indexed: 11/13/2022] Open
Abstract
BACKGROUND Delayed posthemorrhagic vasospasm remains among the major complications after aneurysmal subarachnoid hemorrhage (SAH) and can result in devastating ischemic strokes. As rescue therapy, neurointerventional procedures are used for selective vasodilatation. OBJECTIVE To investigate the effects of intra-arterial papaverine-hydrochloride on cerebral metabolism and oxygenation. METHODS A total of 10 consecutive patients, suffering from severe aneurysmal SAH were prospectively included. Patients were under continuous multimodality neuromonitoring and required intra-arterial papaverine-hydrochloride for vasospasm unresponsive to hypertensive therapy. Cerebral metabolism (microdialysis), brain tissue oxygen tension (ptiO2), intracranial pressure (ICP), and cerebral perfusion pressure (CPP) were analyzed for a period of 12 h following intervention. RESULTS A median dose of 125 mg papaverine-hydrochloride was administered ipsilateral to the multimodality probe. Angiographic improvement of cerebral vasospasm was observed in 80% of patients. During intervention, a significant elevation of ICP (13.7 ± 5.2 mmHg) and the lactate-pyruvate ratio (LPR) (54.2 ± 15.5) was observed, whereas a decrease in cerebral glucose (0.9 ± 0.5 mmol/L) occurred. Within an hour, an increase of cerebral lactate (5.0 ± 2.0 mmol/L) and glycerol (104.4 ± 89.8 μmol/L) as well as a decrease of glucose (0.9 ± 0.4 mmol/L) were measured. In 2 to 5 h after treatment, the LPR significantly decreased (pretreatment: 39.3 ± 15.3, to lowest 30.5 ± 6.7). Cerebral pyruvate levels increased in 1 to 10 h (pretreatment: 100.1 ± 33.1 μmol/L, to highest 141.4 ± 33.7 μmol/L) after intervention. No significant changes in ptiO2 or CPP occurred. CONCLUSION The initial detrimental effects of the endovascular procedure itself were outweighed by an improved cerebral metabolism within 10 h thereafter. As the effect was very limited, repeated interventions or continuous application should be considered.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Adrian Engel
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Johannes Herta
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Walter Plöchl
- Department of Anesthesia, General Intensive Care Medicine and Pain Management, Medical University of Vienna, Vienna, Austria
| | - Andrea Reinprecht
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Andreas Gruber
- Department of Neurosurgery, Kepler Universitätsklinikum, Johannes Kepler University Linz, Linz, Austria
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Khatibi K, Szeder V, Blanco MB, Tateshima S, Jahan R, Duckwiler G, Vespa P. Role of Bedside Multimodality Monitoring in the Detection of Cerebral Vasospasm Following Subarachnoid Hemorrhage. ACTA NEUROCHIRURGICA SUPPLEMENT 2020; 127:141-144. [DOI: 10.1007/978-3-030-04615-6_20] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
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Consenso internacional sobre la monitorización de la presión tisular cerebral de oxígeno en pacientes neurocríticos. Neurocirugia (Astur) 2020; 31:24-36. [DOI: 10.1016/j.neucir.2019.08.003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/12/2019] [Accepted: 08/11/2019] [Indexed: 01/20/2023]
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Hosmann A, Rauscher S, Wang WT, Dodier P, Bavinzski G, Knosp E, Gruber A. Intra-Arterial Papaverine-Hydrochloride and Transluminal Balloon Angioplasty for Neurointerventional Management of Delayed-Onset Post-Aneurysmal Subarachnoid Hemorrhage Vasospasm. World Neurosurg 2018; 119:e301-e312. [PMID: 30053563 DOI: 10.1016/j.wneu.2018.07.138] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/21/2018] [Revised: 07/13/2018] [Accepted: 07/14/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE After subarachnoid hemorrhage, delayed onset vasospasm can result in devastating ischemic stroke. The phenomenon of delayed cerebral ischemia (DCI) is not yet fully understood, and the correlation of angiographic vasospasm and cerebral infarction is still unclear. Therefore, we investigated the effect of endovascular treatment on the angiographic response and occurrence of DCI. METHODS Eighty patients with subarachnoid hemorrhage and serious cerebral vasospasm underwent endovascular treatment using intra-arterial papaverine-hydrochloride (IAP) or transluminal balloon angioplasty (TBA). The angiographic response and infarction rate were classified using the pre- and postinterventional angiographic images and computed tomography scans. RESULTS In 90% of patients, vasospasm could be improved. In most cases (78.8%), IAP was used. Retreatment after IAP was necessary in 32.9% of patients but never after TBA. A total of 233 vascular territories were treated in 128 procedures. Angiographic improvement was observed in 66.5% of territories, which was significantly associated with early intervention (P = 0.02), the use of TBA (P = 0.01), and the dose of papaverine-hydrochloride (P = 0.01). DCI occurred in 47.5% of the patients. Territorial infarction was associated with a poor Hunt and Hess grade (P = 0.03), day of aneurysm treatment (P = 0.01), severe vasospasm before (P = 0.02) and after (P = 0.03) treatment, and number of interventions (P = 0.01). However, the infarction rate was independent of the angiographic response. CONCLUSION The discrepancy of excellent angiographic results and the high incidence of DCI might stem from an inaccurate or a delayed diagnosis of impending ischemia. In view of the limited time window, optimized peri-interventional management and continuous cerebral multimodality neuromonitoring might be crucial for the ideal timing of endovascular procedures to prevent cerebral infarctions.
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Affiliation(s)
- Arthur Hosmann
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Steffen Rauscher
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Wei-Te Wang
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Philippe Dodier
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Gerhard Bavinzski
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria
| | - Engelbert Knosp
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria.
| | - Andreas Gruber
- Department of Neurosurgery, Medical University of Vienna, Vienna, Austria; Department of Neurosurgery, Kepler Universitätsklinikum, Johannes Kepler University Linz, Linz, Austria
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Jones S, Schwartzbauer G, Jia X. Brain Monitoring in Critically Neurologically Impaired Patients. Int J Mol Sci 2016; 18:E43. [PMID: 28035993 PMCID: PMC5297678 DOI: 10.3390/ijms18010043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/10/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023] Open
Abstract
Assessment of neurologic injury and the evolution of severe neurologic injury is limited in comatose or critically ill patients that lack a reliable neurologic examination. For common yet severe pathologies such as the comatose state after cardiac arrest, aneurysmal subarachnoid hemorrhage (aSAH), and severe traumatic brain injury (TBI), critical medical decisions are made on the basis of the neurologic injury. Decisions regarding active intensive care management, need for neurosurgical intervention, and withdrawal of care, depend on a reliable, high-quality assessment of the true state of neurologic injury, and have traditionally relied on limited assessments such as intracranial pressure monitoring and electroencephalogram. However, even within TBI there exists a spectrum of disease that is likely not captured by such limited monitoring and thus a more directed effort towards obtaining a more robust biophysical signature of the individual patient must be undertaken. In this review, multimodal monitoring including the most promising serum markers of neuronal injury, cerebral microdialysis, brain tissue oxygenation, and pressure reactivity index to access brain microenvironment will be discussed with their utility among specific pathologies that may help determine a more complete picture of the neurologic injury state for active intensive care management and long-term outcomes. Goal-directed therapy guided by a multi-modality approach appears to be superior to standard intracranial pressure (ICP) guided therapy and should be explored further across multiple pathologies. Future directions including the application of optogenetics to evaluate brain injury and recovery and even as an adjunct monitoring modality will also be discussed.
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Affiliation(s)
- Salazar Jones
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Abstract
Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.
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Rasmussen R, Bache S, Stavngaard T, Skjøth-Rasmussen J, Romner B. Real-time changes in brain tissue oxygen during endovascular treatment of cerebral vasospasm. ACTA NEUROCHIRURGICA. SUPPLEMENT 2015; 120:183-186. [PMID: 25366621 DOI: 10.1007/978-3-319-04981-6_31] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/04/2023]
Abstract
The use of endovascular intervention to treat cerebral vasospasm after subarachnoid hemorrhage has increased. Although the effect on angiographic vasospasm can be easily demonstrated, the effect on cerebral blood flow and clinical outcome is still controversial. In this report, we investigate minute-by-minute changes in brain tissue oxygen during balloon angioplasty and intraarterial administration of vasodilators in three patients.Our results confirm that endovascular intervention is capable of not only resolving angiographic vasospasm, but also of normalizing values of brain tissue oxygen pressure (PtiO₂) in target parenchyma. However, during the intervention, dangerously low levels of brain tissue oxygen, leading to cerebral infarction, may occur. Thus, no clinical improvement was seen in two of the patients and a dramatic worsening was observed in the third patient. Because the decrease in brain tissue oxygen was seen after administration of vasopressor agents, this may be a contributing factor.
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Affiliation(s)
- Rune Rasmussen
- Department of Neurosurgery, Copenhagen University Hospital, 9 Blegdamsvej, Copenhagen, Denmark,
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De Georgia MA. Brain Tissue Oxygen Monitoring in Neurocritical Care. J Intensive Care Med 2014; 30:473-83. [PMID: 24710714 DOI: 10.1177/0885066614529254] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2013] [Accepted: 01/14/2014] [Indexed: 11/15/2022]
Abstract
Brain injury results from ischemia, tissue hypoxia, and a cascade of secondary events. The cornerstone of neurocritical care management is optimization and maintenance of cerebral blood flow (CBF) and oxygen and substrate delivery to prevent or attenuate this secondary damage. New techniques for monitoring brain tissue oxygen tension (PtiO2) are now available. Brain PtiO2 reflects both oxygen delivery and consumption. Brain hypoxia (low brain PtiO2) has been associated with poor outcomes in patients with brain injury. Strategies to improve brain PtiO2 have focused mainly on increasing oxygen delivery either by increasing CBF or by increasing arterial oxygen content. The results of nonrandomized studies comparing brain PtiO2-guided therapy with intracranial pressure/cerebral perfusion pressure-guided therapy, while promising, have been mixed. More studies are needed including prospective, randomized controlled trials to assess the true value of this approach. The following is a review of the physiology of brain tissue oxygenation, the effect of brain hypoxia on outcome, strategies to increase oxygen delivery, and outcome studies of brain PtiO2-guided therapy in neurocritical care.
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Affiliation(s)
- Michael A De Georgia
- Case Western Reserve University School of Medicine, Neurological Institute, University Hospitals Case Medical Center, Cleveland, OH, USA
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