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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).
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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
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Ocamoto GN, da Silva LN, da Silva Rocha Tomaz C, Hisatugu MT, Frigieri G, Cardim D, Gonçalves RL, Russo TL, de Amorim RLO. Characterization of intracranial compliance in healthy subjects using a noninvasive method - results from a multicenter prospective observational study. J Clin Monit Comput 2024:10.1007/s10877-024-01191-w. [PMID: 39031230 DOI: 10.1007/s10877-024-01191-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/01/2024] [Accepted: 06/25/2024] [Indexed: 07/22/2024]
Abstract
PURPOSE An FDA-approved non-invasive intracranial pressure (ICP) monitoring system enables the assessment of ICP waveforms by revealing and analyzing their morphological variations and parameters associated with intracranial compliance, such as the P2/P1 ratio and time-to-peak (TTP). The aim of this study is to characterize intracranial compliance in healthy volunteers across different age groups. METHODS Healthy participants, both sexes, aged from 9 to 74 years old were monitored for 5 min in the supine position at 0º. Age was stratified into 4 groups: children (≤ 7 years); young adults (18 ≤ age ≤ 44 years); middle-aged adults (45 ≤ age ≤ 64 years); older adults (≥ 65 years). The data obtained was the non-invasive ICP waveform, P2/P1 ratio and TTP. RESULTS From December 2020 to February 2023, 188 volunteers were assessed, of whom 104 were male, with a median (interquartile range) age of 41 (29-51), and a median (interquartile range) body mass index of 25.09 (22.57-28.04). Men exhibited lower values compared to women for both the P2/P1 ratio and TTP (p < 0.001). There was a relative rise in both P2/P1 and TTP as age increased (p < 0.001). CONCLUSIONS The study revealed that the P2/P1 ratio and TTP are influenced by age and sex in healthy individuals, with men displaying lower values than women, and both ratios increasing with age. These findings suggest potential avenues for further research with larger and more diverse samples to establish reference values for comparison in various health conditions. TRIAL REGISTRATION Brazilian Registry of Clinical Trials (RBR-9nv2h42), retrospectively registered 05/24/2022. UTN: U1111-1266-8006.
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Affiliation(s)
- Gabriela Nagai Ocamoto
- Braincare Desenvolvimento e Inovação Tecnológica S.A., Bruno Ruggiero Filho Avenue, 971, São Carlos, São Paulo, 13562-420, Brazil.
| | - Lucas Normando da Silva
- Health Sciences Postgraduation Program, Federal University of Amazonas, General Rodrigo Octavio Jordão Ramos Avenue, 1200, Manaus, Amazonas, 69067-005, Brazil
| | - Camila da Silva Rocha Tomaz
- Braincare Desenvolvimento e Inovação Tecnológica S.A., Bruno Ruggiero Filho Avenue, 971, São Carlos, São Paulo, 13562-420, Brazil
| | - Matheus Toshio Hisatugu
- Braincare Desenvolvimento e Inovação Tecnológica S.A., Bruno Ruggiero Filho Avenue, 971, São Carlos, São Paulo, 13562-420, Brazil
| | - Gustavo Frigieri
- Braincare Desenvolvimento e Inovação Tecnológica S.A., Bruno Ruggiero Filho Avenue, 971, São Carlos, São Paulo, 13562-420, Brazil
- Medical Investigation Laboratory 62, University of São Paulo School of Medicine, São Paulo, Brazil
| | - Danilo Cardim
- Braincare Desenvolvimento e Inovação Tecnológica S.A., Bruno Ruggiero Filho Avenue, 971, São Carlos, São Paulo, 13562-420, Brazil
| | - Roberta Lins Gonçalves
- Health Sciences Postgraduation Program, Federal University of Amazonas, General Rodrigo Octavio Jordão Ramos Avenue, 1200, Manaus, Amazonas, 69067-005, Brazil
| | - Thiago Luiz Russo
- Department of Physical Therapy, Federal University of São Carlos, Washington Luís Road, km 235, São Carlos, São Paulo, 13565-905, Brazil
| | - Robson Luis Oliveira de Amorim
- Health Sciences Postgraduation Program, Federal University of Amazonas, General Rodrigo Octavio Jordão Ramos Avenue, 1200, Manaus, Amazonas, 69067-005, Brazil
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Brasil S, Romeijn H, Haspels EK, Paiva W, Schaafsma A. Improved Transcranial Doppler Waveform Analysis for Intracranial Hypertension Assessment in Patients with Traumatic Brain Injury. Neurocrit Care 2024; 40:931-940. [PMID: 37932509 DOI: 10.1007/s12028-023-01849-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/17/2023] [Accepted: 08/28/2023] [Indexed: 11/08/2023]
Abstract
BACKGROUND Transcranial Doppler (TCD) is a noninvasive bedside tool for cerebral hemodynamic assessments in multiple clinical scenarios. TCD, by means of measuring systolic and diastolic blood velocities, allows the calculation of the pulsatility index (PI), a parameter that is correlated with intracranial pressure (ICP). Nevertheless, the predictive value of the PI for raised ICP appears to be low, as it is subjected to several, often confounding, factors not related to ICP. Recently, the pulsatile apparent resistance (PaR) index was developed as a PI corrected for arterial blood pressure, reducing some of the confounding factors influencing PI. This study compares the predictive value of PaR versus PI for intracranial hypertension (IH) (ICP > 20 mm Hg) in patients with traumatic brain injury. METHODS Patients with traumatic brain injury admitted to the neurocritical care unit who required invasive ICP monitoring were included prospectively within 5 days of admission. TCD measurements were performed in both middle cerebral arteries, allowing calculations of the PI and PaR. The optimal cutoff, discriminative power of these parameters for ICP ≥ 20 mm Hg, was assessed by calculating the area under the receiver operator characteristics curve (AUC). RESULTS In total, 93 patients were included. A total of 20 (22%) patients experienced IH during the recording sessions. The discriminative power was low for PI (AUC 0.63) but slightly higher for PaR (AUC 0.77). Nonparametric analysis indicated significant difference for PaR when comparing patients with (median 0.169) and without IH (median - 0.052, p = 0.001), whereas PI medians for patients with and without IH were 0.86 and 0.77, respectively (p = 0.041). Regarding subanalyses, the discriminative power of these parameters increased after exclusion of patients who had undergone a neurosurgical procedure. This was especially true for the PaR (AUC 0.89) and PI (AUC 0.72). Among these patients, a PaR cutoff value of - 0.023 had 100% sensitivity and 52.9% specificity. CONCLUSIONS In the present study, discriminative power of the PaR for discriminating IH was superior to the PI. The PaR seems to be a reliable noninvasive parameter for detecting IH. Further studies are warranted to define its clinical application, especially in aiding neurosurgical decision making, following up in intensive care units, and defining its ability to indicate responses according to the therapies administered.
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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.
| | - Hannah Romeijn
- Intensive Care Department, Martini General Hospital, Groningen, The Netherlands
| | - Esther K Haspels
- Intensive Care Department, Martini General Hospital, Groningen, The Netherlands
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Arjen Schaafsma
- Department of Clinical Neurophysiology, Martini General Hospital, Groningen, The Netherlands
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Ziółkowski A, Kasprowicz M, Kazimierska A, Czosnyka M. Quantitative analysis of similarity between cerebral arterial blood volume and intracranial pressure pulse waveforms during intracranial pressure plateau waves. BRAIN & SPINE 2024; 4:102832. [PMID: 38756859 PMCID: PMC11096935 DOI: 10.1016/j.bas.2024.102832] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/19/2023] [Revised: 04/25/2024] [Accepted: 05/06/2024] [Indexed: 05/18/2024]
Abstract
Introduction Both intracranial pressure (ICP) and cerebral arterial blood volume (CaBV) have a pulsatile character related to the cardiac cycle. The evolution of the shape of ICP pulses under increasing ICP or decreasing intracranial compliance is well documented. Nevertheless, the exact origin of the alterations in the ICP morphology remains unclear. Research question Does ICP pulse waveform become similar to non-invasively estimated CaBV pulse during ICP plateau waves. Material and methods A total of 15 plateau waves recorded in 15 traumatic brain injured patients were analyzed. CaBV pulse waveforms were calculated using global cerebral blood flow model from transcranial Doppler cerebral blood flow velocity (CBFV) signals. The difference index (DI) was used to quantify the similarity between ICP and CaBV waveforms. DI was calculated as the sum of absolute sample-by-sample differences between ICP and CaBV waveforms, representing the area between the pulses. Results ICP increased (19.4 mm Hg [Q1-Q3: 18.2-23.4 mm Hg] vs. 42.7 mm Hg [Q1-Q3: 36.5-45.1 mm Hg], p < 0.001) while CBFV decreased (44.2 cm/s [Q1-Q3: 34.8-69.5 cm/s] vs. 32.9 cm/s [Q1-Q3: 24.7-68.2 cm/s], p = 0.002) during plateau waves. DI was smaller during the plateau waves (20.4 [Q1-Q3: 15.74-23.0]) compared to the baselines (26.3 [Q1-Q3: 24.2-34.7], p < 0.001). Discussion and conclusion The area between corresponding ICP and CaBV pulse waveforms decreased during the plateau waves which suggests they became similar in shape. CaBV may play a significant role in determining the shape of ICP pulses during the plateau waves and might be a driving force in formulating ICP elevation.
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Affiliation(s)
- Arkadiusz Ziółkowski
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Agnieszka Kazimierska
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Faculty of Electronics and Information Technology, Warsaw University of Technology, Warsaw, Poland
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Cherain LGG, Barbosa MGDS, Francisco GGDOA, Cherain LMG, Frigieri G, Rabelo NN. Age as a predictive factor for reduced intracranial compliance in patients with headache. ARQUIVOS DE NEURO-PSIQUIATRIA 2024; 82:1-6. [PMID: 38395417 PMCID: PMC10890915 DOI: 10.1055/s-0044-1779029] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Subscribe] [Scholar Register] [Received: 02/13/2023] [Accepted: 10/20/2023] [Indexed: 02/25/2024]
Abstract
BACKGROUND Increased intracranial pressure (ICP) consists of a set of signs and symptoms related to changes in intracranial compliance (ICC) and ICP. OBJECTIVE This study presents a retrospective analysis of patients who underwent non-invasive monitoring of ICC based on complaints of headache, correlating decreased brain compliance and increased intracranial pressure. METHODS Noninvasive ICC monitoring was performed using a Brain4care device, which contains a strain gauge and a recorder connected to a mechanical device that touches the scalp surface in the frontoparietal area lateral to the sagittal suture. This tool monitors the ICP by identifying small changes in skull measurements that are caused by pressure variations, i.e., skull deformation is associated with the detection of changes in mean ICP. A clinical evaluation of 32 patients with complaints of headache occurred from the analysis of their medical records. RESULTS Of the 32 patients initially chosen, it was possible to complete the analysis of 18 due to the availability of data in the medical records. From the non-invasive monitoring of the ICC, the following data were collected: time-to-peak, P2/P1 ratio, age, and gender. From the statistical analysis of age and P2/P1 ratio, it was noted that as age increases, ICC tends to decrease regardless of sex (p < 0.05). CONCLUSION This study concluded that there is a correlation between changes in intracranial compliance and headache complaints in outpatients. There was also a relationship between age and decreased intracranial compliance but without a specific pain pattern.
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Brasil S, Godoy DA, Hawryluk GWJ. A Point-of-Care Noninvasive Technique for Surrogate ICP Waveforms Application in Neurocritical Care. Neurocrit Care 2024; 40:170-176. [PMID: 37438552 PMCID: PMC10861641 DOI: 10.1007/s12028-023-01786-2] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2023] [Accepted: 06/12/2023] [Indexed: 07/14/2023]
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil.
| | - Daniel A Godoy
- Neurointensive Care Unit, Sanatório Pasteur, Catamarca, Argentina
| | - Gregory W J Hawryluk
- Department of Neurosurgery, Cleveland Clinic and Akron General Hospital, Fairlawn, OH, USA
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Gulamali F, Jayaraman P, Sawant AS, Desman J, Fox B, Chang A, Soong BY, Arivazaghan N, Reynolds AS, Duong SQ, Vaid A, Kovatch P, Freeman R, Hofer IS, Sakhuja A, Dangayach NS, Reich DS, Charney AW, Nadkarni GN. Derivation, External Validation and Clinical Implications of a deep learning approach for intracranial pressure estimation using non-cranial waveform measurements. MEDRXIV : THE PREPRINT SERVER FOR HEALTH SCIENCES 2024:2024.01.30.24301974. [PMID: 38352556 PMCID: PMC10863000 DOI: 10.1101/2024.01.30.24301974] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/19/2024]
Abstract
Importance Increased intracranial pressure (ICP) is associated with adverse neurological outcomes, but needs invasive monitoring. Objective Development and validation of an AI approach for detecting increased ICP (aICP) using only non-invasive extracranial physiological waveform data. Design Retrospective diagnostic study of AI-assisted detection of increased ICP. We developed an AI model using exclusively extracranial waveforms, externally validated it and assessed associations with clinical outcomes. Setting MIMIC-III Waveform Database (2000-2013), a database derived from patients admitted to an ICU in an academic Boston hospital, was used for development of the aICP model, and to report association with neurologic outcomes. Data from Mount Sinai Hospital (2020-2022) in New York City was used for external validation. Participants Patients were included if they were older than 18 years, and were monitored with electrocardiograms, arterial blood pressure, respiratory impedance plethysmography and pulse oximetry. Patients who additionally had intracranial pressure monitoring were used for development (N=157) and external validation (N=56). Patients without intracranial monitors were used for association with outcomes (N=1694). Exposures Extracranial waveforms including electrocardiogram, arterial blood pressure, plethysmography and SpO2. Main Outcomes and Measures Intracranial pressure > 15 mmHg. Measures were Area under receiver operating characteristic curves (AUROCs), sensitivity, specificity, and accuracy at threshold of 0.5. We calculated odds ratios and p-values for phenotype association. Results The AUROC was 0.91 (95% CI, 0.90-0.91) on testing and 0.80 (95% CI, 0.80-0.80) on external validation. aICP had accuracy, sensitivity, and specificity of 73.8% (95% CI, 72.0%-75.6%), 99.5% (95% CI 99.3%-99.6%), and 76.9% (95% CI, 74.0-79.8%) on external validation. A ten-percentile increment was associated with stroke (OR=2.12; 95% CI, 1.27-3.13), brain malignancy (OR=1.68; 95% CI, 1.09-2.60), subdural hemorrhage (OR=1.66; 95% CI, 1.07-2.57), intracerebral hemorrhage (OR=1.18; 95% CI, 1.07-1.32), and procedures like percutaneous brain biopsy (OR=1.58; 95% CI, 1.15-2.18) and craniotomy (OR = 1.43; 95% CI, 1.12-1.84; P < 0.05 for all). Conclusions and Relevance aICP provides accurate, non-invasive estimation of increased ICP, and is associated with neurological outcomes and neurosurgical procedures in patients without intracranial monitoring.
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Affiliation(s)
- Faris Gulamali
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Pushkala Jayaraman
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ashwin S. Sawant
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Jacob Desman
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Benjamin Fox
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Annie Chang
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Brian Y. Soong
- Department of Medical Education, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Naveen Arivazaghan
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexandra S. Reynolds
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Son Q Duong
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Akhil Vaid
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Patricia Kovatch
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Robert Freeman
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ira S. Hofer
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Ankit Sakhuja
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Neha S. Dangayach
- Department of Neurosurgery and Neurology, Icahn School of Medicine at Mount Sinai, New York, NY
| | - David S. Reich
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Alexander W Charney
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
| | - Girish N. Nadkarni
- The Charles Bronfman Institute of Personalized Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
- The Division of Data Driven and Digital Medicine, Icahn School of Medicine at Mount Sinai, New York, NY
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Szabo S, Totka Z, Nagy-Bozsoky J, Pinter I, Bagany M, Bodo M. Rheoencephalography: A non-invasive method for neuromonitoring. JOURNAL OF ELECTRICAL BIOIMPEDANCE 2024; 15:10-25. [PMID: 38482467 PMCID: PMC10936697 DOI: 10.2478/joeb-2024-0003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 12/07/2023] [Indexed: 04/07/2024]
Abstract
In neurocritical care, the gold standard method is intracranial pressure (ICP) monitoring for the patient's lifesaving. Since it is an invasive method, it is desirable to use an alternative, noninvasive technique. The computerized real-time invasive cerebral blood flow (CBF) autoregulation (AR) monitoring calculates the status of CBF AR, called the pressure reactivity index (PRx). Studies documented that the electrical impedance of the head (Rheoencephalography - REG) can detect the status of CBF AR (REGx) and ICP noninvasively. We aimed to test REG to reflect ICP and CBF AR. For nineteen healthy subjects we recorded bipolar bifrontal and bitemporal REG derivations and arm bioimpedance pulses with a 200 Hz sampling rate. The challenges were a 30-second breath-holding and head-down-tilt (HDT - Trendelenburg) position. Data were stored and processed offline. REG pulse wave morphology and REGx were calculated. The most relevant finding was the significant morphological change of the REG pulse waveform (2nd peak increase) during the HDT position. Breath-holding caused REG amplitude increase, but it was not significant. REGx in male and female group averages have similar trends during HDT by indicating the active status of CBF AR. The morphological change of REG pulse wave during HDT position was identical to ICP waveform change during increased ICP, reflecting decreased intracranial compliance. A correlation study between ICP and REG was initiated in neurocritical care patients. The noninvasive REG monitoring would also be useful in space research as well as in military medicine during the transport of wounded service members as well as for fighter pilots to indicate the loss of CBF and consciousness.
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Affiliation(s)
- Sandor Szabo
- University of Szeged, Faculty of General Medicine, Department of Aviation and Space Medicine. Kecskemet, Hungary; Hungarian Defence Forces Medical Center, Aeromedical, Military Medical Screening and Healthcare Instituter;Kecskemet, Hungary
| | - Zsolt Totka
- University of Szeged, Faculty of General Medicine, Department of Aviation and Space Medicine. Kecskemet, Hungary; Hungarian Defence Forces Medical Center, Aeromedical, Military Medical Screening and Healthcare Instituter;Kecskemet, Hungary
| | - Jozsef Nagy-Bozsoky
- University of Szeged, Faculty of General Medicine, Department of Aviation and Space Medicine. Kecskemet, Hungary; Hungarian Defence Forces Medical Center, Aeromedical, Military Medical Screening and Healthcare Instituter;Kecskemet, Hungary
| | | | | | - Michael Bodo
- Uniformed Services University of the Health Sciences, Bethesda, MD, USA
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de Moraes FM, Adissy ENB, Rocha E, Barros FCD, Freitas FGR, Miranda M, Valiente RA, de Andrade JBC, Chaddad-Neto FEA, Silva GS. Multimodal monitoring intracranial pressure by invasive and noninvasive means. Sci Rep 2023; 13:18404. [PMID: 37891406 PMCID: PMC10611734 DOI: 10.1038/s41598-023-45834-5] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2022] [Accepted: 10/24/2023] [Indexed: 10/29/2023] Open
Abstract
Although the placement of an intraventricular catheter remains the gold standard method for the diagnosis of intracranial hypertension (ICH), the technique has several limitations including but not limited to its invasiveness. Current noninvasive methods, however, still lack robust evidence to support their clinical use. We aimed to estimate, as an exploratory hypothesis generating analysis, the discriminative power of four noninvasive methods to diagnose ICH. We prospectively collected data from adult intensive care unit (ICU) patients with subarachnoid hemorrhage (SAH), intraparenchymal hemorrhage (IPH), and ischemic stroke (IS) in whom invasive intracranial pressure (ICP) monitoring had been placed. Measures were simultaneously collected from the following noninvasive methods: optic nerve sheath diameter (ONSD), pulsatility index (PI) using transcranial Doppler (TCD), a 5-point visual scale designed for brain Computed Tomography (CT), and two parameters (time-to-peak [TTP] and P2/P1 ratio) of a noninvasive ICP wave morphology monitor (Brain4Care[B4c]). ICH was defined as a sustained ICP > 20 mmHg for at least 5 min. We studied 18 patients (SAH = 14; ICH = 3; IS = 1) on 60 occasions with a mean age of 52 ± 14.3 years. All methods were recorded simultaneously, except for the CT, which was performed within 24 h of the other methods. The median ICP was 13 [9.8-16.2] mmHg, and intracranial hypertension was present on 18 occasions (30%). Median values from the noninvasive techniques were ONSD 4.9 [4.40-5.41] mm, PI 1.22 [1.04-1.43], CT scale 3 points [IQR: 3.0], P2/P1 ratio 1.16 [1.09-1.23], and TTP 0.215 [0.193-0.237]. There was a significant statistical correlation between all the noninvasive techniques and invasive ICP (ONSD, r = 0.29; PI, r = 0.62; CT, r = 0.21; P2/P1 ratio, r = 0.35; TTP, r = 0.35, p < 0.001 for all comparisons). The area under the curve (AUC) to estimate intracranial hypertension was 0.69 [CIs = 0.62-0.78] for the ONSD, 0.75 [95% CIs 0.69-0.83] for the PI, 0.64 [95%Cis 0.59-069] for CT, 0.79 [95% CIs 0.72-0.93] for P2/P1 ratio, and 0.69 [95% CIs 0.60-0.74] for TTP. When the various techniques were combined, an AUC of 0.86 [0.76-0.93]) was obtained. The best pair of methods was the TCD and B4cth an AUC of 0.80 (0.72-0.88). Noninvasive technique measurements correlate with ICP and have an acceptable discrimination ability in diagnosing ICH. The multimodal combination of PI (TCD) and wave morphology monitor may improve the ability of the noninvasive methods to diagnose ICH. The observed variability in non-invasive ICP estimations underscores the need for comprehensive investigations to elucidate the optimal method-application alignment across distinct clinical scenarios.
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Affiliation(s)
| | | | - Eva Rocha
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Maramelia Miranda
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | - Raul Alberto Valiente
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
| | | | | | - Gisele Sampaio Silva
- Neurology and Neurosurgery Department, Federal University of São Paulo, São Paulo, Brazil
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10
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Kazimierska A, Manet R, Vallet A, Schmidt E, Czosnyka Z, Czosnyka M, Kasprowicz M. Analysis of intracranial pressure pulse waveform in studies on cerebrospinal compliance: a narrative review. Physiol Meas 2023; 44:10TR01. [PMID: 37793420 DOI: 10.1088/1361-6579/ad0020] [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: 04/15/2023] [Accepted: 10/04/2023] [Indexed: 10/06/2023]
Abstract
Continuous monitoring of mean intracranial pressure (ICP) has been an essential part of neurocritical care for more than half a century. Cerebrospinal pressure-volume compensation, i.e. the ability of the cerebrospinal system to buffer changes in volume without substantial increases in ICP, is considered an important factor in preventing adverse effects on the patient's condition that are associated with ICP elevation. However, existing assessment methods are poorly suited to the management of brain injured patients as they require external manipulation of intracranial volume. In the 1980s, studies suggested that spontaneous short-term variations in the ICP signal over a single cardiac cycle, called the ICP pulse waveform, may provide information on cerebrospinal compensatory reserve. In this review we discuss the approaches that have been proposed so far to derive this information, from pulse amplitude estimation and spectral techniques to most recent advances in morphological analysis based on artificial intelligence solutions. Each method is presented with focus on its clinical significance and the potential for application in standard clinical practice. Finally, we highlight the missing links that need to be addressed in future studies in order for ICP pulse waveform analysis to achieve widespread use in the neurocritical care setting.
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Affiliation(s)
- Agnieszka Kazimierska
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Romain Manet
- Department of Neurosurgery B, Neurological Hospital Pierre Wertheimer, University Hospital of Lyon, Lyon, France
| | - Alexandra Vallet
- Department of Mathematics, University of Oslo, Oslo, Norway
- INSERM U1059 Sainbiose, Ecole des Mines Saint-Étienne, Saint-Étienne, France
| | - Eric Schmidt
- Department of Neurosurgery, University Hospital of Toulouse, Toulouse, France
| | - Zofia Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Magdalena Kasprowicz
- Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
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11
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Brasil S, de Carvalho Nogueira R, Salinet ÂSM, Yoshikawa MH, Teixeira MJ, Paiva W, Malbouisson LMS, Bor-Seng-Shu E, Panerai RB. Critical Closing Pressure and Cerebrovascular Resistance Responses to Intracranial Pressure Variations in Neurocritical Patients. Neurocrit Care 2023; 39:399-410. [PMID: 36869208 PMCID: PMC10541829 DOI: 10.1007/s12028-023-01691-8] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 01/31/2023] [Indexed: 03/05/2023]
Abstract
BACKGROUND Critical closing pressure (CrCP) and resistance-area product (RAP) have been conceived as compasses to optimize cerebral perfusion pressure (CPP) and monitor cerebrovascular resistance, respectively. However, for patients with acute brain injury (ABI), the impact of intracranial pressure (ICP) variability on these variables is poorly understood. The present study evaluates the effects of a controlled ICP variation on CrCP and RAP among patients with ABI. METHODS Consecutive neurocritical patients with ICP monitoring were included along with transcranial Doppler and invasive arterial blood pressure monitoring. Internal jugular veins compression was performed for 60 s for the elevation of intracranial blood volume and ICP. Patients were separated in groups according to previous intracranial hypertension severity, with either no skull opening (Sk1), neurosurgical mass lesions evacuation, or decompressive craniectomy (DC) (patients with DC [Sk3]). RESULTS Among 98 included patients, the correlation between change (Δ) in ICP and the corresponding ΔCrCP was strong (group Sk1 r = 0.643 [p = 0.0007], group with neurosurgical mass lesions evacuation r = 0.732 [p < 0.0001], and group Sk3 r = 0.580 [p = 0.003], respectively). Patients from group Sk3 presented a significantly higher ΔRAP (p = 0.005); however, for this group, a higher response in mean arterial pressure (change in mean arterial pressure p = 0.034) was observed. Exclusively, group Sk1 disclosed reduction in ICP before internal jugular veins compression withholding. CONCLUSIONS This study elucidates that CrCP reliably changes in accordance with ICP, being useful to indicate ideal CPP in neurocritical settings. In the early days after DC, cerebrovascular resistance seems to remain elevated, despite exacerbated arterial blood pressure responses in efforts to maintain CPP stable. Patients with ABI with no need of surgical procedures appear to remain with more effective ICP compensatory mechanisms when compared with those who underwent neurosurgical interventions.
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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.
| | - Ricardo de Carvalho Nogueira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Ângela Salomão Macedo Salinet
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Márcia Harumy Yoshikawa
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Wellingson Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | | | - Edson Bor-Seng-Shu
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, Av. Dr. Eneas de Carvalho Aguiar 255, São Paulo, Brazil
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, School of Life Sciences, University of Leicester, Leicester, UK
- National Institute for Health and Care Research, Cardiovascular Research Centre, Glenfield Hospital, University of Leicester, Leicester, UK
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12
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Brasil S, Godoy DA. A new noninvasive method can effectively assess intracranial compliance. Letter to the Editor. Acta Neurochir (Wien) 2023; 165:2213-2214. [PMID: 37217760 PMCID: PMC10409651 DOI: 10.1007/s00701-023-05644-0] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/19/2023] [Accepted: 04/20/2023] [Indexed: 05/24/2023]
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.
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13
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Link C, D`Haese TM, Frigieri G, Brasil S, Vellosa JCR, Welling L. Intracranial compliance and volumetry in patients with traumatic brain injury. Surg Neurol Int 2023; 14:246. [PMID: 37560593 PMCID: PMC10408625 DOI: 10.25259/sni_314_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2023] [Accepted: 06/27/2023] [Indexed: 08/11/2023] Open
Abstract
BACKGROUND Cerebral edema (CE) and intracranial hypertension (IHT) are complications of numerous neurological pathologies. However, the study of CE and noninvasive methods to predict IHT remains rudimentary. This study aims to identify in traumatic brain injury (TBI) patients the relationship between the volume of the lateral ventricles and the parameters of the noninvasive intracranial pressure waveform (nICPW). METHODS This is an analytical, descriptive, and cross-sectional study with nonsurgical TBI patients. The monitoring of nICPW was performed with a mechanical strain gauge, and the volumetry of the lateral ventricles was calculated using the free 3D Slicer software, both during the acute phase of the injury. The linear model of fixed and random mixed effects with Gamma was used to calculate the influence of nICPW parameters (P2/P1 and time-to-peak [TTP]) values on volumetry. RESULTS Considering only the fixed effects of the sample, there was P = 0.727 (95% CI [-0.653; 0.364]) for the relationship between P2/P1 and volumetry and 0.727 (95% CI [-1.657; 1.305]) for TTP and volumetry. Considering the fixed and random effects, there was P = 8.5e-10 (95% CI [-0.759; 0.355]) for the relationship between P2/P1 and volumetry and 8.5e-10 (95% CI [-2.001; 0.274]) for TTP and volumetry. CONCLUSION The present study with TBI patients found association between nICPW parameters and the volume of the lateral ventricles in the 1st days after injury.
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Affiliation(s)
- Caroline Link
- Department of Neurology, Clinics Hospital Complex of the Federal University of Paraná, Curitiba, Brazil
| | - Thomas Markus D`Haese
- Department of Intensive care, State University of Ponta Grossa, Ponta Grossa, Brazil
| | - Gustavo Frigieri
- Braincare Desenvolvimento e Inovação Tecnológica SA - Brain4care, São Carlos, Brazil
| | - Sérgio Brasil
- Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil
| | | | - Leonardo Welling
- Neurological Surgery, State University of Ponta Grossa, Ponta Grossa, Brazil
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14
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Faria BCD, Sacramento LGG, Queiroz AVR, Leite FDAD, Oliveira HLLLD, Kimura TY, Faleiro RM. The use of noninvasive measurements of intracranial pressure in patients with traumatic brain injury: a narrative review. ARQUIVOS DE NEURO-PSIQUIATRIA 2023; 81:551-563. [PMID: 37379867 DOI: 10.1055/s-0043-1764411] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/30/2023]
Abstract
BACKGROUND The most frequent cause of death in neurosurgical patients is due to the increase in intracranial pressure (ICP); consequently, adequate monitoring of this parameter is extremely important. OBJECTIVES In this study, we aimed to analyze the accuracy of noninvasive measurement methods for intracranial hypertension (IH) in patients with traumatic brain injury (TBI). METHODS The data were obtained from the PubMed database, using the following terms: intracranial pressure, noninvasive, monitoring, assessment, and measurement. The selected articles date from 1980 to 2021, all of which were observational studies or clinical trials, in English and specifying ICP measurement in TBI. At the end of the selection, 21 articles were included in this review. RESULTS The optic nerve sheath diameter (ONSD), pupillometry, transcranial doppler (TCD), multimodal combination, brain compliance using ICP waveform (ICPW), HeadSense, and Visual flash evoked pressure (FVEP) were analyzed. Pupillometry was not found to correlate with ICP, while HeadSense monitor and the FVEP method appear to have good correlation, but sensitivity and specificity data are not available. The ONSD and TCD methods showed good-to-moderate accuracy on invasive ICP values and potential to detect IH in most studies. Furthermore, multimodal combination may reduce the error possibility related to each technique. Finally, ICPW showed good accuracy to ICP values, but this analysis included TBI and non-TBI patients in the same sample. CONCLUSIONS Noninvasive ICP monitoring methods may be used in the near future to guide TBI patients' management.
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Affiliation(s)
| | | | | | | | | | - Thais Yuki Kimura
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte MG, Brazil
| | - Rodrigo Moreira Faleiro
- Universidade Federal de Minas Gerais, Faculdade de Medicina, Belo Horizonte MG, Brazil
- Faculdade de Ciências Médicas de Minas Gerais, Belo Horizonte MG, Brazil
- Hospital João XXIII, Belo Horizonte MG, Brazil
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15
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Godoy DA, Brasil S, Iaccarino C, Paiva W, Rubiano AM. The intracranial compartmental syndrome: a proposed model for acute brain injury monitoring and management. Crit Care 2023; 27:137. [PMID: 37038236 PMCID: PMC10088257 DOI: 10.1186/s13054-023-04427-4] [Citation(s) in RCA: 11] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 04/02/2023] [Indexed: 04/12/2023] Open
Abstract
For decades, one of the main targets in the management of severe acute brain injury (ABI) has been intracranial hypertension (IH) control. However, the determination of IH has suffered variations in its thresholds over time without clear evidence for it. Meanwhile, progress in the understanding of intracranial content (brain, blood and cerebrospinal fluid) dynamics and recent development in monitoring techniques suggest that targeting intracranial compliance (ICC) could be a more reliable approach rather than guiding actions by predetermined intracranial pressure values. It is known that ICC impairment forecasts IH, as intracranial volume may rapidly increase inside the skull, a closed bony box with derisory expansibility. Therefore, an intracranial compartmental syndrome (ICCS) can occur with deleterious brain effects, precipitating a reduction in brain perfusion, thereby inducing brain ischemia. The present perspective review aims to discuss the ICCS concept and suggest an integrative model for the combination of modern invasive and noninvasive techniques for IH and ICC assessment. The theory and logic suggest that the combination of multiple ancillary methods may enhance ICC impairment prediction, pointing proactive actions and improving patient outcomes.
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Affiliation(s)
| | - Sérgio Brasil
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil.
| | - Corrado Iaccarino
- Department of Biomedical, Metabolic and Neural Sciences, University Modena and Reggio Emilia, Modena, Italy
- Department of Neurosurgery, University Hospital of Modena, Modena, Italy
- Emergency Neurosurgery, AUSLRE IRCCS, Reggio Emilia, Italy
| | - Wellingson Paiva
- Experimental Surgery Laboratory and Division of Neurological Surgery, University of São Paulo Medical School, Av. Eneas de Carvalho Aguiar 255, Sao Paulo, Brazil
| | - Andres M Rubiano
- Universidad El Bosque. Bogotá, Bogotá, Colombia
- MEDITECH Foundation, Cali, Colombia
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16
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Frigieri G, Robba C, Machado FS, Gomes JA, Brasil S. Application of non-invasive ICP waveform analysis in acute brain injury: Intracranial Compliance Scale. Intensive Care Med Exp 2023; 11:5. [PMID: 36703025 PMCID: PMC9880126 DOI: 10.1186/s40635-023-00492-9] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/01/2022] [Accepted: 01/05/2023] [Indexed: 01/28/2023] Open
Affiliation(s)
- Gustavo Frigieri
- grid.11899.380000 0004 1937 0722Medical Investigation Laboratory 62, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Chiara Robba
- grid.5606.50000 0001 2151 3065Department of Intensive Care, Universitá Degli Studi Di Genoa, Genova, Italy
| | - Fábio Santana Machado
- grid.413471.40000 0000 9080 8521Department of Intensive Care, Hospital Sírio Libanês, São Paulo, Brazil
| | - Joao A. Gomes
- grid.239578.20000 0001 0675 4725Cerebrovascular Center, Neurologic Institute, Cleveland Clinic, Cleveland, OH USA
| | - Sérgio Brasil
- grid.11899.380000 0004 1937 0722Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, São Paulo, Brazil
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17
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Dixon B, Sharkey JM, Teo EJ, Grace SA, Savage JS, Udy A, Smith P, Hellerstedt J, Santamaria JD. Assessment of a Non-Invasive Brain Pulse Monitor to Measure Intra-Cranial Pressure Following Acute Brain Injury. MEDICAL DEVICES (AUCKLAND, N.Z.) 2023; 16:15-26. [PMID: 36718229 PMCID: PMC9883992 DOI: 10.2147/mder.s398193] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 11/29/2022] [Accepted: 01/13/2023] [Indexed: 01/26/2023]
Abstract
Background Intracranial pressure (ICP) monitoring requires placing a hole in the skull through which an invasive pressure monitor is inserted into the brain. This approach has risks for the patient and is expensive. We have developed a non-invasive brain pulse monitor that uses red light to detect a photoplethysmographic (PPG) signal arising from the blood vessels on the brain's cortical surface. The brain PPG and the invasive ICP waveform share morphological features which may allow measurement of the intracranial pressure. Methods We enrolled critically ill patients with an acute brain injury with invasive ICP monitoring to assess the new monitor. A total of 24 simultaneous invasive ICP and brain pulse monitor PPG measurements were undertaken in 12 patients over a range of ICP levels. Results The waveform morphologies were similar for the invasive ICP and brain pulse monitor PPG approach. Both methods demonstrated a progressive increase in the amplitude of P2 relative to P1 with increasing ICP levels. An automated algorithm was developed to assess the PPG morphological features in relation to the ICP level. A correlation was demonstrated between the brain pulse waveform morphology and ICP levels, R2=0.66, P < 0.001. Conclusion The brain pulse monitor's PPG waveform demonstrated morphological features were similar to the invasive ICP waveform over a range of ICP levels, these features may provide a method to measure ICP levels. Trial Registration ACTRN12620000828921.
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Affiliation(s)
- Barry Dixon
- Cyban Pty Ltd, Melbourne, VIC, Australia,Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia,Department of Medicine, University of Melbourne, Melbourne, Vic, Australia,Correspondence: Barry Dixon, Department of Critical Care Medicine, St Vincent’s Hospital (Melbourne), 41 Victoria Parade, Fitzroy, VIC, 3065, Australia, Tel +61 3 9231 4425, Email
| | | | - Elliot J Teo
- Cyban Pty Ltd, Melbourne, VIC, Australia,Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia
| | | | | | - Andrew Udy
- Department of Critical Care Medicine, The Alfred Hospital, Melbourne, Australia
| | - Paul Smith
- Department of Neurosurgery, St Vincent’s Hospital, Melbourne, Australia,University of Melbourne Medical School, Melbourne, Vic, Australia
| | | | - John D Santamaria
- Department of Critical Care Medicine, St Vincent’s Hospital, Melbourne, Australia
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18
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Brasil S, Frigieri G, Taccone FS, Robba C, Solla DJF, de Carvalho Nogueira R, Yoshikawa MH, Teixeira MJ, Malbouisson LMS, Paiva WS. Noninvasive intracranial pressure waveforms for estimation of intracranial hypertension and outcome prediction in acute brain-injured patients. J Clin Monit Comput 2022; 37:753-760. [PMID: 36399214 PMCID: PMC9673225 DOI: 10.1007/s10877-022-00941-y] [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] [Received: 07/27/2022] [Accepted: 10/27/2022] [Indexed: 11/19/2022]
Abstract
Analysis of intracranial pressure waveforms (ICPW) provides information on intracranial compliance. We aimed to assess the correlation between noninvasive ICPW (NICPW) and invasively measured intracranial pressure (ICP) and to assess the NICPW prognostic value in this population. In this cohort, acute brain-injured (ABI) patients were included within 5 days from admission in six Intensive Care Units. Mean ICP (mICP) values and the P2/P1 ratio derived from NICPW were analyzed and correlated with outcome, which was defined as: (a) early death (ED); survivors on spontaneous breathing (SB) or survivors on mechanical ventilation (MV) at 7 days from inclusion. Intracranial hypertension (IHT) was defined by ICP > 20 mmHg. A total of 72 patients were included (mean age 39, 68% TBI). mICP and P2/P1 values were significantly correlated (r = 0.49, p < 0.001). P2/P1 ratio was significantly higher in patients with IHT and had an area under the receiving operator curve (AUROC) to predict IHT of 0.88 (95% CI 0.78–0.98). mICP and P2/P1 ratio was also significantly higher for ED group (n = 10) than the other groups. The AUROC of P2/P1 to predict ED was 0.71 [95% CI 0.53–0.87], and the threshold P2/P1 > 1.2 showed a sensitivity of 60% [95% CI 31–83%] and a specificity of 69% [95% CI 57–79%]. Similar results were observed when decompressive craniectomy patients were excluded. In this study, P2/P1 derived from noninvasive ICPW assessment was well correlated with IHT. This information seems to be as associated with ABI patients outcomes as ICP. Trial registration: NCT03144219, Registered 01 May 2017 Retrospectively registered, https://www.clinicaltrials.gov/ct2/show/NCT03144219.
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Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Gustavo Frigieri
- Medical Investigation Laboratory 62, School of Medicine, University of São Paulo, São Paulo, Brazil
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hôpital, Université Libre de Bruxelles, Bruxelles, Belgium
| | - Chiara Robba
- Department of Intensive Care, Universitá degli Studi di Genoa, Genoa, Italy
| | - Davi Jorge Fontoura Solla
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Ricardo de Carvalho Nogueira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Marcia Harumy Yoshikawa
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | - Manoel Jacobsen Teixeira
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
| | | | - Wellingson Silva Paiva
- Division of Neurosurgery, Department of Neurology, School of Medicine, University of São Paulo, 255 Enéas Aguiar Street, São Paulo, 05403000 Brazil
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19
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Brasil S. Intracranial pressure pulse morphology: the missing link? Intensive Care Med 2022; 48:1667-1669. [PMID: 36038714 PMCID: PMC9592648 DOI: 10.1007/s00134-022-06855-2] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 07/30/2022] [Indexed: 11/29/2022]
Affiliation(s)
- Sérgio Brasil
- Division of Neurosurgery, Department of Neurology, University of São Paulo School of Medicine, 255 Enéas Aguiar Street, São Paulo, 05403000, Brazil.
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20
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Galdino GAM, Moura-Tonello SCG, Linares SN, Milan-Mattos JC, Spavieri DL, Oliveira SM, Porta A, Beltrame T, Catai AM. Intracranial compliance in type 2 diabetes mellitus and its relationship with the cardiovascular autonomic nervous control. Braz J Med Biol Res 2022; 55:e12150. [PMID: 36102416 PMCID: PMC9467282 DOI: 10.1590/1414-431x2022e12150] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2022] [Accepted: 07/11/2022] [Indexed: 11/29/2022] Open
Abstract
The intracranial compliance in type 2 diabetes mellitus (T2DM) patients and the association with cardiovascular autonomic control have not been fully elucidated. The aim of this study was to assess intracranial compliance using the noninvasive intracranial pressure (niICP) and the monitoring of waveform peaks (P1, P2, and P3) and the relationship with cardiovascular autonomic control in T2DM patients. Thirty-two men aged 40-60 years without cardiovascular autonomic neuropathy (CAN) were studied: T2DMG (n=16) and control group CG (n=16). The niICP was evaluated by a noninvasive extracranial sensor placed on the scalp. Cardiovascular autonomic control was evaluated by indices of the baroreflex sensitivity (BRS), from temporal series of R-R intervals of electrocardiogram and systolic arterial pressure, during supine and orthostatic positions. The participants remained in the supine position for 15 min and then 15 min more in orthostatism. T2DMG presented a decrease of the P2/P1 ratio during the orthostatic position (P<0.001). There was a negative moderate correlation between the P2 peak with cardiovascular coupling (K2HP-SAPLF) in supine (r=-0.612, P=0.011) and orthostatic (r=-0.568, P=0.020) positions in T2DMG. We concluded that T2DM patients without CAN and cardiovascular complications presented intracranial compliance similar to healthy subjects. Despite preserved intracranial adjustments, T2DM patients had a response of greater magnitude in orthostatism. In addition, the decoupling between the heart period and blood pressure signal oscillations in low frequency appeared to be related to the worsening of intracranial compliance due to the increased P2 peak.
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Affiliation(s)
- G A M Galdino
- Laboratório de Fisioterapia Cardiovascular, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brasil
| | - S C G Moura-Tonello
- Laboratório de Fisioterapia Cardiovascular, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brasil
| | - S N Linares
- Laboratório de Fisioterapia Cardiovascular, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brasil
| | - J C Milan-Mattos
- Laboratório de Fisioterapia Cardiovascular, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brasil
| | - D L Spavieri
- Divisão de Ciência de Dados, brain4care, São Carlos, SP, Brasil
| | - S M Oliveira
- Divisão de Ciência de Dados, brain4care, São Carlos, SP, Brasil.,Instituto de Física de São Carlos, Universidade de São Paulo, São Carlos, SP, Brasil
| | - A Porta
- Department of Biomedical Sciences for Health, University of Milan, Milan, Italy.,Department of Cardiothoracic, Vascular Anesthesia and Intensive Care, IRCCS Policlinico San Donato, Milan, Italy
| | - T Beltrame
- Laboratório de Fisioterapia Cardiovascular, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brasil.,Samsung R&D Institute Brazil (SRBR), Campinas, SP, Brasil
| | - A M Catai
- Laboratório de Fisioterapia Cardiovascular, Departamento de Fisioterapia, Universidade Federal de São Carlos, São Carlos, SP, Brasil
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Gholampour S, Yamini B, Droessler J, Frim D. A New Definition for Intracranial Compliance to Evaluate Adult Hydrocephalus After Shunting. Front Bioeng Biotechnol 2022; 10:900644. [PMID: 35979170 PMCID: PMC9377221 DOI: 10.3389/fbioe.2022.900644] [Citation(s) in RCA: 13] [Impact Index Per Article: 6.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2022] [Accepted: 06/13/2022] [Indexed: 12/26/2022] Open
Abstract
The clinical application of intracranial compliance (ICC), ∆V/∆P, as one of the most critical indexes for hydrocephalus evaluation was demonstrated previously. We suggest a new definition for the concept of ICC (long-term ICC) where there is a longer amount of elapsed time (up to 18 months after shunting) between the measurement of two values (V1 and V2 or P1 and P2). The head images of 15 adult patients with communicating hydrocephalus were provided with nine sets of imaging in nine stages: prior to shunting, and 1, 2, 3, 6, 9, 12, 15, and 18 months after shunting. In addition to measuring CSF volume (CSFV) in each stage, intracranial pressure (ICP) was also calculated using fluid–structure interaction simulation for the noninvasive calculation of ICC. Despite small increases in the brain volume (16.9%), there were considerable decreases in the ICP (70.4%) and CSFV (80.0%) of hydrocephalus patients after 18 months of shunting. The changes in CSFV, brain volume, and ICP values reached a stable condition 12, 15, and 6 months after shunting, respectively. The results showed that the brain tissue needs approximately two months to adapt itself to the fast and significant ICP reduction due to shunting. This may be related to the effect of the “viscous” component of brain tissue. The ICC trend between pre-shunting and the first month of shunting was descending for all patients with a “mean value” of 14.75 ± 0.6 ml/cm H2O. ICC changes in the other stages were oscillatory (nonuniform). Our noninvasive long-term ICC calculations showed a nonmonotonic trend in the CSFV–ICP graph, the lack of a linear relationship between ICC and ICP, and an oscillatory increase in ICC values during shunt treatment. The oscillatory changes in long-term ICC may reflect the clinical variations in hydrocephalus patients after shunting.
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22
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Abstract
PURPOSE OF REVIEW The aim of this study was to provide an overview on advances in intracranial pressure (ICP) protocols for care, moving from traditional to more recent concepts. RECENT FINDINGS Deep understanding of mechanics and dynamics of fluids and solids have been introduced for intracranial physiology. The amplitude or the harmonics of the cerebral-spinal fluid and the cerebral blood waves shows more information about ICP than just a numeric threshold. When the ICP overcome the compensatory mechanisms that maintain the compliance within the skull, an intracranial compartment syndrome (ICCS) is defined. Autoregulation monitoring emerge as critical tool to recognize CPP management. Measurement of brain tissue oxygen will be a critical intervention for diagnosing an ICCS. Surgical procedures focused on increasing the physiological compliance and increasing the volume of the compartments of the skull. SUMMARY ICP management is a complex task, moving far than numeric thresholds for activation of interventions. The interactions of intracranial elements requires new interpretations moving beyond classical theories. Most of the traditional clinical studies supporting ICP management are not generating high class evidence. Recommendations for ICP management requires better designed clinical studies using new concepts to generate interventions according to the new era of personalized medicine.
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Rossi DM, Bevilaqua-Grossi D, Mascarenhas S, de Souza HCD, Carvalho GF, Vendramim ACC, Philbois SV, Dach F, Tallarico FJ, de Oliveira AS. Noninvasive intracranial pressure monitoring in women with migraine. Sci Rep 2022; 12:2635. [PMID: 35173207 PMCID: PMC8850543 DOI: 10.1038/s41598-022-06258-9] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/18/2021] [Accepted: 01/25/2022] [Indexed: 11/17/2022] Open
Abstract
This cross-sectional study aimed to compare the waveform morphology through noninvasive intracranial pressure (ICP-NI) measurement between patients with migraine and controls, and to analyze the association with clinical variables. Twenty-nine women with migraine, age 32.4 (11.2) years and headache frequency of 12.6 (7.5) days per month and twenty-nine women without headache, age 32.1 (9.0) years, were evaluated. Pain intensity, migraine disability, allodynia, pain catastrophizing, central sensitization and depression were evaluated. The ICP-NI monitoring was performed by a valid method consisting of an extracranial deformation sensor positioned in the patients’ scalp, which allowed registration of intracranial pressure waveforms. Heart rate and blood pressure measurements were simultaneously recorded during 20 min in the supine position. The analyzed parameter was the P2/P1 ratio based on mean pulse per minute which P1 represents the percussion wave related to the arterial blood pression maximum and P2 the tidal wave, middle point between the P1 maximum and the dicrotic notch. There was no between-groups difference in the P2/P1 ratio (mean difference: 0.04, IC95%: -0.07 to 0.16, p = 0.352, F (1,1) = 0.881) adjusted by body mass index covariable. The Multiple Linear Regression showed non-statistical significance [F (5,44) = 1.104; p = 0.372; R2 = 0.11)] between the P2/P1 ratio and body mass index, presence of migraine, central sensitization, pain catastrophizing and depression. We found no correlation (p > 0.05) between P2/P1 ratio and migraine frequency, migraine onset, pain intensity, pain intensity at day of examination, disability, allodynia. Migraine patients did not present alterations in the waveform morphology through ICP-NI compared to women without headache and no association with clinical variables was found.
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Affiliation(s)
- Denise Martineli Rossi
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Department of Applied Physiotherapy, Federal University of Triângulo Mineiro, Uberaba, Minas Gerais, Brazil
| | - Débora Bevilaqua-Grossi
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Sérgio Mascarenhas
- São Carlos Institute of Physics, University of São Paulo, São Carlos, Brazil
| | - Hugo Celso Dutra de Souza
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Gabriela Ferreira Carvalho
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.,Institut für Gesundheitswissenschaften, Studiengang Physiotherapie, Pain and Exercise Research Luebeck (P.E.R.L), Universität zu Lübeck, Lübeck, Germany
| | - Ana Carolina Carmona Vendramim
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Stella Vieira Philbois
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil
| | - Fabíola Dach
- Department of Neurosciences and Behavioral Sciences, Ribeirão Preto Medical School, University of São Paulo, Ribeirão Preto, Brazil
| | | | - Anamaria Siriani de Oliveira
- Ribeirão Preto Medical School, Department of Health Sciences, University of São Paulo, Ribeirão Preto, São Paulo, Brazil.
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