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Kattan L. Unexplained Intraoperative Movement During a Complex Craniotomy for Recurrent Petrous Apex Cholesterol Granuloma: A Case Report. Cureus 2024; 16:e70660. [PMID: 39493083 PMCID: PMC11528619 DOI: 10.7759/cureus.70660] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 10/01/2024] [Indexed: 11/05/2024] Open
Abstract
Intraoperative patient movement under general anesthesia, even with multiple monitoring modalities and adequate anesthetic depth, is rare but can lead to serious complications. Such movements are particularly dangerous in neurosurgical procedures, where precision is crucial. Similar risks exist in ophthalmic, spinal, and cardiac surgeries, where patient immobilization is vital to prevent adverse outcomes. This report examines the case of a 37-year-old male diagnosed with recurrent cholesterol granuloma located at the petrous apex, which necessitated neurosurgical intervention. During the procedure, the patient was placed under deep general anesthesia, and multiple neuromonitoring techniques were used to track neural and motor activity. Despite maintaining stable hemodynamic parameters and unremarkable neuromonitoring results, the patient suddenly exhibited abrupt, forceful movements involving his head and upper arms. This unexpected event during a delicate neurosurgical procedure posed a significant challenge, prompting a deeper investigation into the possible underlying causes of the patient's sudden movements, which could include factors such as insufficient anesthetic depth, muscular or neural irritation, seizure activity, or mechanical factors related to surgical equipment or technique. This case highlights the critical role of comprehensive intraoperative monitoring in ensuring patient safety, particularly during complex neurosurgical procedures where precision is essential. The use of total intravenous anesthesia (TIVA), as was used in this case, presents unique challenges, as it requires a careful balance of maintaining adequate anesthetic depth without interfering with the neuromonitoring signals used during the procedure to ensure neural integrity.
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Affiliation(s)
- Lamis Kattan
- Anesthesia and Critical Care, King Abdulaziz University Faculty of Medicine, Jeddah, SAU
- Anesthesia and Critical Care, McMaster University, Hamilton, CAN
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2
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Klavansky D, Romero R, Dangayach NS, Nelson SE, Liang J, Reynolds A, Tsetsou S. Multimodal monitoring in patients with acute brain injury - A survey from critical care providers. J Crit Care 2024; 82:154806. [PMID: 38555684 DOI: 10.1016/j.jcrc.2024.154806] [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: 07/26/2023] [Revised: 01/11/2024] [Accepted: 03/27/2024] [Indexed: 04/02/2024]
Abstract
BACKGROUND Multimodal neuromonitoring (MMM) aims to improve outcome after acute brain injury, and thus admission in specialized Neurocritical Care Units with potential access to MMM is necessary. Various invasive and noninvasive modalities have been developed, however there is no strong evidence to support monitor combinations nor is there a known standardized approach. The goal of this study is to identify the most used invasive and non-invasive neuromonitoring modalities in daily practice as well as ubiquitousness of MMM standardization. METHODS In order to investigate current availability and protocolized implementation of MMM among neurocritical care units in US and non-US intensive care units, we designed a cross-sectional survey consisting of a self-administered online questionnaire of 20 closed-ended questions disseminated by the Neurocritical Care Society. RESULTS Twenty-one critical care practitioners responded to our survey with a 76% completion rate. The most commonly utilized non-invasive neuromonitoring modalities were continuous electroencephalography followed by transcranial doppler. The most common invasive modalities were external ventricular drain followed by parenchymal intracranial pressure (ICP) monitoring. MMM is most utilized in patients with subarachnoid hemorrhage and there were no differences regarding established institutional protocol, 24-h cEEG availability and invasive monitor placement between teaching and non-teaching hospitals. MMM is considered standard of care in 28% of responders' hospitals, whereas in 26.7% it is deemed experimental and only done as part of clinical trials. Only 26.7% hospitals use a computerized data integration system. CONCLUSION Our survey revealed overall limited use of MMM with no established institutional protocols among institutions. Ongoing research and further standardization of MMM will clarify its benefit to patients suffering from severe brain injury.
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Affiliation(s)
- Dana Klavansky
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA.
| | - Raquel Romero
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Neha S Dangayach
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Sarah E Nelson
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA; Department of Neurology, Tufts Medical Center, Boston, USA
| | - John Liang
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Alexandra Reynolds
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA
| | - Spyridoula Tsetsou
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, USA; Department of Neurology and Neurosurgery, Baylor College of Medicine, Houston, USA
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3
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Grille P, Biestro A, Rekate HL. Intracranial Hypertension with Patent Basal Cisterns: Controlled Lumbar Drainage as a Therapeutic Option. Selected Case Series. Neurocrit Care 2024; 40:1070-1082. [PMID: 37936017 DOI: 10.1007/s12028-023-01878-z] [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: 02/21/2023] [Accepted: 10/06/2023] [Indexed: 11/09/2023]
Abstract
BACKGROUND There are pathological conditions in which intracranial hypertension and patent basal cisterns in computed tomography coexist. These situations are not well recognized, which could lead to diagnostic errors and improper management. METHODS We present a retrospective case series of patients with traumatic brain injury, subarachnoid hemorrhage, and cryptococcal meningitis who were treated at our intensive care unit. Criteria for deciding placement of an external lumbar drain were (1) intracranial hypertension refractory to osmotherapy, hyperventilation, neuromuscular blockade, intravenous anesthesia, and, in some cases, decompressive craniectomy and (2) a computed tomography scan that showed open basal cisterns and no mass lesion. RESULTS Eleven patients were studied. Six of the eleven patients treated with controlled lumbar drainage are discussed as illustrative cases. All patients developed intracranial hypertension refractory to maximum medical treatment, including decompressive craniectomy in Four of the eleven cases. Controlled external lumbar drainage led to immediate and sustained control of elevated intracranial pressure in all patients, with good neurological outcomes. No brain herniation, intracranial bleeding, or meningitis was detected during this procedure. CONCLUSIONS Our study provides preliminary evidence that in selected patients who develop refractory intracranial hypertension with patent basal cisterns and no focal mass effect on computed tomography, controlled lumbar drainage appears to be a therapeutic option. In our study there were no deaths or complications. Prospective and larger studies are needed to confirm our results.
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Affiliation(s)
- Pedro Grille
- Intensive Care Unit, Hospital Maciel, Administración de los Servicios de Salud del Estado (ASSE), 25 de Mayo 174, 11000, Montevideo, Uruguay.
| | - Alberto Biestro
- Intensive Care Unit, Facultad de Medicina, Hospital de Clínicas, Universidad de la República, Montevideo, Uruguay
| | - Harold L Rekate
- Department of Neurosurgery, Hofstra University, Hempstead, NY, USA
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Cody N, Bradbury I, McMullan RR, Quinn G, O'Neill A, Ward K, McCann J, McAuley DF, Silversides JA. Physiologic Determinants of Near-Infrared Spectroscopy-Derived Cerebral and Tissue Oxygen Saturation Measurements in Critically Ill Patients. Crit Care Explor 2024; 6:e1094. [PMID: 38727717 PMCID: PMC11090623 DOI: 10.1097/cce.0000000000001094] [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] [Indexed: 05/15/2024] Open
Abstract
OBJECTIVES Near-infrared spectroscopy (NIRS) is a potentially valuable modality to monitor the adequacy of oxygen delivery to the brain and other tissues in critically ill patients, but little is known about the physiologic determinants of NIRS-derived tissue oxygen saturations. The purpose of this study was to assess the contribution of routinely measured physiologic parameters to tissue oxygen saturation measured by NIRS. DESIGN An observational sub-study of patients enrolled in the Role of Active Deresuscitation After Resuscitation-2 (RADAR-2) randomized feasibility trial. SETTING Two ICUs in the United Kingdom. PATIENTS Patients were recruited for the RADAR-2 study, which compared a conservative approach to fluid therapy and deresuscitation with usual care. Those included in this sub-study underwent continuous NIRS monitoring of cerebral oxygen saturations (SctO2) and quadriceps muscle tissue saturations (SmtO2). INTERVENTION Synchronized and continuous mean arterial pressure (MAP), heart rate (HR), and pulse oximetry (oxygen saturation, Spo2) measurements were recorded alongside NIRS data. Arterial Paco2, Pao2, and hemoglobin concentration were recorded 12 hourly. Linear mixed effect models were used to investigate the association between these physiologic variables and cerebral and muscle tissue oxygen saturations. MEASUREMENTS AND MAIN RESULTS Sixty-six patients were included in the analysis. Linear mixed models demonstrated that Paco2, Spo2, MAP, and HR were weakly associated with SctO2 but only explained 7.1% of the total variation. Spo2 and MAP were associated with SmtO2, but together only explained 0.8% of its total variation. The remaining variability was predominantly accounted for by between-subject differences. CONCLUSIONS Our findings demonstrated that only a small proportion of variability in NIRS-derived cerebral and tissue oximetry measurements could be explained by routinely measured physiologic variables. We conclude that for NIRS to be a useful monitoring modality in critical care, considerable further research is required to understand physiologic determinants and prognostic significance.
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Affiliation(s)
- Neil Cody
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Ian Bradbury
- Independent Consulting Statistician, Aviemore, Scotland
| | - Ross R McMullan
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Gerard Quinn
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Aisling O'Neill
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Kathryn Ward
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Justine McCann
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
| | - Daniel F McAuley
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
| | - Jonathan A Silversides
- Intensive Care Department, Belfast Health and Social Care Trust, Belfast, Northern Ireland
- Wellcome-Wolfson Institute for Experimental Medicine, Queen's University Belfast, Belfast, Northern Ireland
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5
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Murray DS, Stickel L, Boutelle M. Computational Modeling as a Tool to Drive the Development of a Novel, Chemical Device for Monitoring the Injured Brain and Body. ACS Chem Neurosci 2023; 14:3599-3608. [PMID: 37737666 PMCID: PMC10557062 DOI: 10.1021/acschemneuro.3c00063] [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: 02/01/2023] [Accepted: 09/06/2023] [Indexed: 09/23/2023] Open
Abstract
Real-time measurement of dynamic changes, occurring in the brain and other parts of the body, is useful for the detection and tracked progression of disease and injury. Chemical monitoring of such phenomena exists but is not commonplace, due to the penetrative nature of devices, the lack of continuous measurement, and the inflammatory responses that require pharmacological treatment to alleviate. Soft, flexible devices that more closely match the moduli and shape of monitored tissue and allow for surface microdialysis provide a viable alternative. Here, we show that computational modeling can be used to aid the development of such devices and highlight the considerations when developing a chemical monitoring probe in this way. These models pave the way for the development of a new class of chemical monitoring devices for monitoring neurotrauma, organs, and skin.
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Affiliation(s)
- De-Shaine Murray
- Department
of Bioengineering, Imperial College London SW7 2AZ, London, U.K.
- School
of Engineering and Applied Sciences, Yale
University, 06520, New Haven, Connecticut United States
| | - Laure Stickel
- Department
of Bioengineering, Imperial College London SW7 2AZ, London, U.K.
- Laboratoire
Physico-Chimie Curie, Institut Curie, 26 rue d’Ulm, 75005, Paris, France
| | - Martyn Boutelle
- Department
of Bioengineering, Imperial College London SW7 2AZ, London, U.K.
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Lin IH, Kamnaksh A, Aniceto R, McCullough J, Bekdash R, Eklund M, Ghatan PH, Risling M, Svensson M, Bellander BM, Nelson DW, Thelin EP, Agoston DV. Time-Dependent Changes in the Biofluid Levels of Neural Injury Markers in Severe Traumatic Brain Injury Patients-Cerebrospinal Fluid and Cerebral Microdialysates: A Longitudinal Prospective Pilot Study. Neurotrauma Rep 2023; 4:107-117. [PMID: 36895820 PMCID: PMC9989523 DOI: 10.1089/neur.2022.0076] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 03/05/2023] Open
Abstract
Monitoring protein biomarker levels in the cerebrospinal fluid (CSF) can help assess injury severity and outcome after traumatic brain injury (TBI). Determining injury-induced changes in the proteome of brain extracellular fluid (bECF) can more closely reflect changes in the brain parenchyma, but bECF is not routinely available. The aim of this pilot study was to compare time-dependent changes of S100 calcium-binding protein B (S100B), neuron-specific enolase (NSE), total Tau, and phosphorylated Tau (p-Tau) levels in matching CSF and bECF samples collected at 1, 3, and 5 days post-injury from severe TBI patients (n = 7; GCS 3-8) using microcapillary-based western analysis. We found that time-dependent changes in CSF and bECF levels were most pronounced for S100B and NSE, but there was substantial patient-to-patient variability. Importantly, the temporal pattern of biomarker changes in CSF and bECF samples showed similar trends. We also detected two different immunoreactive forms of S100B in both CSF and bECF samples, but the contribution of the different immunoreactive forms to total immunoreactivity varied from patient to patient and time point to time point. Our study is limited, but it illustrates the value of both quantitative and qualitative analysis of protein biomarkers and the importance of serial sampling for biofluid analysis after severe TBI.
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Affiliation(s)
- I-Hsuan Lin
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Alaa Kamnaksh
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Roxanne Aniceto
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Jesse McCullough
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Ramsey Bekdash
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Michael Eklund
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
| | - Per Hamid Ghatan
- Department of Neuroscience, Uppsala University Hospital, Uppsala, Sweden
| | - Mårten Risling
- Department of Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Mikael Svensson
- Department of Clinical Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - Bo-Michael Bellander
- Department of Clinical Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurosurgery, Karolinska University Hospital, Stockholm, Sweden
| | - David W Nelson
- Department of Perioperative Medicine and Intensive Care, Karolinska University Hospital, Stockholm, Sweden.,Section of Perioperative Medicine and Intensive Care, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden
| | - Eric Peter Thelin
- Department of Clinical Neuroscience, Department of Physiology and Pharmacology, Karolinska Institutet, Stockholm, Sweden.,Department of Neurology, Karolinska University Hospital, Stockholm, Sweden
| | - Denes V Agoston
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland, USA
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7
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Cruz Navarro J, Ponce Mejia LL, Robertson C. A Precision Medicine Agenda in Traumatic Brain Injury. Front Pharmacol 2022; 13:713100. [PMID: 35370671 PMCID: PMC8966615 DOI: 10.3389/fphar.2022.713100] [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: 05/21/2021] [Accepted: 02/25/2022] [Indexed: 11/13/2022] Open
Abstract
Traumatic brain injury remains a leading cause of death and disability across the globe. Substantial uncertainty in outcome prediction continues to be the rule notwithstanding the existing prediction models. Additionally, despite very promising preclinical data, randomized clinical trials (RCTs) of neuroprotective strategies in moderate and severe TBI have failed to demonstrate significant treatment effects. Better predictive models are needed, as the existing validated ones are more useful in prognosticating poor outcome and do not include biomarkers, genomics, proteonomics, metabolomics, etc. Invasive neuromonitoring long believed to be a "game changer" in the care of TBI patients have shown mixed results, and the level of evidence to support its widespread use remains insufficient. This is due in part to the extremely heterogenous nature of the disease regarding its etiology, pathology and severity. Currently, the diagnosis of traumatic brain injury (TBI) in the acute setting is centered on neurological examination and neuroimaging tools such as CT scanning and MRI, and its treatment has been largely confronted using a "one-size-fits-all" approach, that has left us with many unanswered questions. Precision medicine is an innovative approach for TBI treatment that considers individual variability in genes, environment, and lifestyle and has expanded across the medical fields. In this article, we briefly explore the field of precision medicine in TBI including biomarkers for therapeutic decision-making, multimodal neuromonitoring, and genomics.
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Affiliation(s)
- Jovany Cruz Navarro
- Departments of Anesthesiology and Neurosurgery, Baylor College of Medicine, Houston, TX, United States
| | - Lucido L. Ponce Mejia
- Departments of Neurosurgery and Neurology, LSU Health Science Center, New Orleans, LA, United States
| | - Claudia Robertson
- Department of Neurosurgery, Baylor College of Medicine, Houston, TX, United States
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Treichl SA, Ho WM, Steiger R, Grams AE, Rietzler A, Luger M, Gizewski ER, Thomé C, Petr O. Cerebral Energy Status and Altered Metabolism in Early Brain Injury After Aneurysmal Subarachnoid Hemorrhage: A Prospective 31P-MRS Pilot Study. Front Neurol 2022; 13:831537. [PMID: 35295831 PMCID: PMC8919991 DOI: 10.3389/fneur.2022.831537] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2021] [Accepted: 02/01/2022] [Indexed: 11/16/2022] Open
Abstract
Background Acute changes of cerebral energy metabolism in early brain injury (EBI) after aneurysmal subarachnoid hemorrhage (aSAH) may play a crucial role for overall neurological outcome. However, direct detection of these alterations is limited. Phosphorous magnetic resonance spectroscopy (31P-MRS) is a molecular-based advanced neuroimaging technique allowing measurements of pathophysiological processes and tissue metabolism based on various phosphorous compound metabolites. This method may provide objective assessment of both primary and secondary changes. Objective The aim of this pilot study was to evaluate the feasibility and the diagnostic potential of early 31P-MRS in aSAH. Methods Patients with aSAH treated for ruptured aneurysms between July 2016 and October 2017 were prospectively included in the study. 3-Tesla-MRI including 31P-MRS was performed within the first 72 h after hemorrhage. Data of the vascular territories of the anterior, middle, and posterior cerebral arteries (ACA, MCA, PCA) and the basal ganglia were separately analyzed and compared with data of a healthy age- and sex-matched control group. Phosphorous compound metabolites were quantified, and ratios of these metabolites were further evaluated. Influence of treatment modality, clinical conditions, and analgosedation were analyzed. Results Data of 13 patients were analyzed. 31P-MRS showed significant changes in cerebral energy metabolism after aSAH in all cerebrovascular territories. Both PCr/ATP and PCr/Pi ratio were notably increased (P < 0.001). Also, Pi/ATP was significantly decreased in all cerebrovascular territories (P = 0.014). PME/PDE ratio was overall significant decreased (P < 0.001). Conclusion 31P-MRS is a promising non-invasive imaging tool for the assessment of changes in energy metabolism after aSAH. It allows a detailed insight into EBI and seems to harbor a high potential for clinical practice.
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Affiliation(s)
| | - Wing Mann Ho
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ruth Steiger
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- *Correspondence: Ruth Steiger
| | - Astrid Ellen Grams
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
| | - Andreas Rietzler
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Markus Luger
- Neuroimaging Research Core Facility, Medical University of Innsbruck, Innsbruck, Austria
| | - Elke Ruth Gizewski
- Department of Neuroradiology, Medical University of Innsbruck, Innsbruck, Austria
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thomé
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Ondra Petr
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
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9
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Hosomi S, Sobue T, Kitamura T, Ogura H, Shimazu T. Nationwide improvements in geriatric mortality due to traumatic brain injury in Japan. BMC Emerg Med 2022; 22:24. [PMID: 35144534 PMCID: PMC8830138 DOI: 10.1186/s12873-022-00577-w] [Citation(s) in RCA: 9] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/17/2021] [Accepted: 01/27/2022] [Indexed: 11/10/2022] Open
Abstract
BACKGROUND Traumatic brain injury (TBI), both isolated and in combination with extracranial lesions, is a global health problem associated with high mortality. Among various risk factors for poor clinical outcomes, age is the most important independent predictor of mortality in patients with TBI. TBI-related mortality is expected to increase as the society ages. However, in a super-aged society such as Japan, little is known about the trend of TBI-related mortality among older adults. Herein, we assessed the nationwide trend of the incidence and clinical outcomes of geriatric patients with TBI in Japan using the national Japanese Trauma Data Bank (JTDB) registry. METHODS In this retrospective cohort study, cases of TBI (aged ≥65 years) in hospitals registered with the JTDB database between January 2004 and December 2018 were included. In-hospital mortality was the primary outcome, and mortality in the emergency department was the secondary outcome. The odds ratios (ORs) and 95% confidence intervals (CIs) for in-hospital deaths with respect to 3-year periods were assessed using multivariable analysis after adjusting for potential confounders. RESULTS The main cause of TBI in older individuals was falls. The proportion of patients who died after hospitalization during the study period decreased markedly from 29.5% (194/657) during 2004-2006 to 14.2% (1309/9240) during 2016-2018 in the isolated TBI group (adjusted OR = 0.42, 95% CI: 0.33-0.53) and from 48.0% (119/248) during 2004-2006 to 21.7% (689/3172) during 2016-2018 in the multiple trauma group (adjusted OR = 0.32, 95% CI: 0.23-0.45). The adjusted ORs for the 3-year increment were 0.84 (95% CI: 0.81-0.88) and 0.78 (95% CI: 0.75-0.83) for the isolated TBI and multiple trauma groups, respectively. CONCLUSIONS Using the national JTDB registry, we demonstrated a nationwide reduction in TBI-related mortality. Our findings in the super-aged society of Japan may provide insight for the treatment of geriatric patients with TBI worldwide.
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Affiliation(s)
- Sanae Hosomi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan. .,Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Japan.
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-2, Yamada-oka, Suita, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15 Yamadaoka, Suita-shi, Osaka, 565-0871, Japan
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10
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Luz Teixeira T, Peluso L, Banco P, Njimi H, Abi-Khalil L, Chanchay Pillajo M, Schuind S, Creteur J, Bouzat P, Taccone FS. Early Pupillometry Assessment in Traumatic Brain Injury Patients: A Retrospective Study. Brain Sci 2021; 11:brainsci11121657. [PMID: 34942959 PMCID: PMC8699519 DOI: 10.3390/brainsci11121657] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/14/2021] [Revised: 12/06/2021] [Accepted: 12/13/2021] [Indexed: 01/31/2023] Open
Abstract
BACKGROUND The aim of this study was to evaluate whether the early assessment of neurological pupil index (NPi) values derived from automated pupillometry could predict neurological outcome after traumatic brain injury (TBI). METHODS Retrospective observational study including adult (>18 years) TBI patients admitted from January 2018 to December 2020, with available NPi on admission. Abnormal NPi was considered if <3. Unfavorable neurological outcome (UO) at hospital discharge was considered for a Glasgow Outcome Scale of 1-3. RESULTS 100 patients were included over the study period (median age 48 (34-69) years and median GCS on admission 11 (6-15)); 49 (49%) patients had UO. On admission, 20 (20%) patients had an abnormal NPi (NPi < 3); median worst (i.e., from both eyes) NPi was 4.2 (3.2-4.5). Median worst and mean NPi on admission were significantly lower in the UO group than others (3.9 (1.7-4.4) vs. 4.4 (3.7-4.6); p = 0.005-4.0 (2.6-4.5) vs. 4.5 (3.9-4.7); p = 0.002, respectively). The ROC curve for the worst and mean NPi showed a moderate accuracy to predict UO (AUC 0.66 (0.56-0.77); p = 0.005 and 0.68 (0.57-0.78); p = 0.002). However, in a generalized linear model, the prognostic role of NPi on admission was limited. CONCLUSIONS Low NPi on admission has limited prognostic value in TBI.
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Affiliation(s)
- Thomas Luz Teixeira
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Lorenzo Peluso
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Pierluigi Banco
- Department of Anesthesiology and Intensive Care, University of Grenobles, 38400 Grenobles, France; (P.B.); (P.B.)
| | - Hassane Njimi
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Layal Abi-Khalil
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Mélanie Chanchay Pillajo
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Sophie Schuind
- Department of Neurosurgery, Hopital Erasme, Université Libre de Bruxelles (ULB), 1070 Brussels, Belgium;
| | - Jacques Creteur
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
| | - Pierre Bouzat
- Department of Anesthesiology and Intensive Care, University of Grenobles, 38400 Grenobles, France; (P.B.); (P.B.)
- Grenoble Institute Neurosciences, University of Grenoble Alpes, 38700 Grenoble, France
| | - Fabio Silvio Taccone
- Department of Intensive Care, Hopital Erasme, Université Libre de Bruxelles (ULB), 1050 Brussels, Belgium; (T.L.T.); (L.P.); (H.N.); (L.A.-K.); (M.C.P.); (J.C.)
- Correspondence: ; Tel.: +32-25555587
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11
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Hosomi S, Sobue T, Kitamura T, Hirayama A, Ogura H, Shimazu T. Association between vasopressor use and mortality in patients with severe traumatic brain injury: a nationwide retrospective cohort study in Japan. Acute Med Surg 2021; 8:e695. [PMID: 34567578 PMCID: PMC8448585 DOI: 10.1002/ams2.695] [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: 05/07/2021] [Revised: 07/14/2021] [Accepted: 09/01/2021] [Indexed: 11/23/2022] Open
Abstract
Aim Vasopressors are frequently incorporated into severe traumatic brain injury management algorithms. However, evidence regarding their clinical effectiveness is lacking. We undertook a nationwide retrospective cohort study to determine the association between vasopressor use and mortality in patients with severe traumatic brain injury. Methods Data were collected between January 2004 and December 2018 from the Japanese Trauma Data Bank, which includes data from 272 emergency hospitals in Japan. Adults aged 16 years and over with severe traumatic brain injury but without major extracranial injuries were examined. A severe traumatic brain injury was defined based on a Glasgow Coma Scale score of 3–8 on admission. Multivariable analysis and propensity score matching were carried out. Statistical significance was assessed using 95% confidence intervals. Results In total, 10,295 patients were eligible for analysis, with 654 included in the vasopressor group and 9,641 included in the nonvasopressor group. The proportion of deaths at hospital discharge was higher in the vasopressor group than in the nonvasopressor group (81.80% [535/654] versus 40.24% [3,880/9,641]). This finding was confirmed in a multivariable logistic regression analysis (adjusted odds ratio, 5.37; 95% confidence interval, 4.23–6.81). Among propensity score‐matched patients adjusted for severity, the proportion of deaths at hospital discharge remained higher in the vasopressor group than in the nonvasopressor group (81.87% [533/651] versus 56.22% [366/651]) (odds ratio, 3.52; 95% confidence interval, 2.73–4.53). Conclusion The study results suggest that vasopressor use in patients with severe isolated traumatic brain injury is associated with a higher mortality at hospital discharge.
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Affiliation(s)
- Sanae Hosomi
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Osaka Japan.,Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Atsushi Hirayama
- Division of Environmental Medicine and Population Sciences Department of Social and Environmental Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Osaka Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine Osaka University Graduate School of Medicine Osaka Japan
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12
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Hosomi S, Kitamura T, Sobue T, Ogura H, Shimazu T. Survival outcomes after traumatic brain injury during national academic meeting days in Japan. Sci Rep 2021; 11:15206. [PMID: 34312458 PMCID: PMC8313689 DOI: 10.1038/s41598-021-94759-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 07/15/2021] [Indexed: 11/09/2022] Open
Abstract
Surgeons and medical staff attend academic meetings several times a year. However, there is insufficient evidence on the influence of the “meeting effect” on traumatic brain injury (TBI) treatments and outcomes. Using the Japan Trauma Data Bank, we analyzed the data of TBI patients admitted to the hospital from 2004 to 2018 during the national academic meeting days of the Japanese Association for Acute Medicine, the Japanese Society of Intensive Care Medicine, the Japanese Association for the surgery of trauma, the Japan Society of Neurotraumatology and the Japan Neurosurgical Society. The data of these patients were compared with those of TBI patients admitted 1 week before and after the meetings. The primary outcome was in-hospital death. We included 7320 patients in our analyses, with 5139 and 2181 patients admitted during the non-meeting and meeting days, respectively; their in-hospital mortality rates were 15.7% and 14.5%, respectively. No significant differences in in-hospital mortality were found (adjusted odds ratio, 0.93; 95% confidence interval, 0.78–1.11). In addition, there were no significant differences in in-hospital mortality during the meeting and non-meeting days by the type of national meeting. In Japan, it is acceptable for medical professionals involved in TBI treatments to attend national academic meetings without impacting the outcomes of TBI patients.
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Affiliation(s)
- Sanae Hosomi
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871, Japan. .,Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Japan.
| | - Tetsuhisa Kitamura
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Japan
| | - Tomotaka Sobue
- Division of Environmental Medicine and Population Sciences, Department of Social and Environmental Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Japan
| | - Hiroshi Ogura
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871, Japan
| | - Takeshi Shimazu
- Department of Traumatology and Acute Critical Medicine, Osaka University Graduate School of Medicine, 2-15, Yamadaoka, Suita, Osaka, 565-0871, Japan
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13
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McCredie VA, Chavarría J, Baker AJ. How do we identify the crashing traumatic brain injury patient - the intensivist's view. Curr Opin Crit Care 2021; 27:320-327. [PMID: 33852501 PMCID: PMC8240643 DOI: 10.1097/mcc.0000000000000825] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
PURPOSE OF REVIEW Over 40% of patients with severe traumatic brain injury (TBI) show clinically significant neurological worsening within the acute admission period. This review addresses the importance of identifying the crashing TBI patient, the difficulties appreciating clinical neurological deterioration in the comatose patient and how neuromonitoring may provide continuous real-time ancillary information to detect physiologic worsening. RECENT FINDINGS The latest editions of the Brain Trauma Foundation's Guidelines omitted management algorithms for adult patients with severe TBI. Subsequently, three consensus-based management algorithms were published using a Delphi method approach to provide a bridge between the evidence-based guidelines and integration of the individual treatment modalities at the bedside. These consensus statements highlight the serious situation of critical deterioration requiring emergent evaluation and guidance on sedation holds to obtain a neurological examination while balancing the potential risks of inducing a stress response. SUMMARY One of the central tenets of neurocritical care is to detect the brain in trouble. The first and most fundamental neurological monitoring tool is the clinical exam. Ancillary neuromonitoring data may provide early physiologic biomarkers to help anticipate, prevent or halt secondary brain injury processes. Future research should seek to understand how data integration and visualization technologies may reduce the cognitive workload to improve timely detection of neurological deterioration.
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Affiliation(s)
- Victoria A. McCredie
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Toronto Western Hospital, University Health Network
- Krembil Research Institute, Toronto Western Hospital
- Department of Critical Care Medicine, Sunnybrook Health Sciences Centre
| | - Javier Chavarría
- Interdepartmental Division of Critical Care Medicine, University of Toronto
| | - Andrew J. Baker
- Interdepartmental Division of Critical Care Medicine, University of Toronto
- Department of Critical Care, St. Michael's Hospital Toronto, University of Toronto
- Department of Anesthesia, Keenan Research Centre for Biomedical Science, St. Michael's Hospital Toronto, University of Toronto, Toronto, Ontario, Canada
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14
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Konar S, Pavlov O, Durango-Espinosa Y, Garcia-Ballestas E, Joaquim AF, Ghosh A, Pal R, Moscote-Salazar LR, Agrawal A. Critical Appraisal of Traumatic Brain Injury and Its Management. INDIAN JOURNAL OF NEUROTRAUMA 2020. [DOI: 10.1055/s-0040-1713555] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
AbstractCritical appraisal of traumatic brain injury (TBI) management has always been marred with a conflict of differential approaches, with claims and counterclaims of outcomes among the research groups. We performed this study to review the management of TBI from risk factors to outcomes including the comorbidities and final clinical status. In conjunction with the aforesaid stabilization of TBI cases, prophylactic and definitive surgical approaches and other supporting interventions will ultimately decide the final outcomes in the long run. Improvements in the quality of care for patients with severe TBI, with the reduction in mortality, have been demonstrated in high-income areas due to improvements in the health care system and not just in one isolated intervention. In the management of TBI, a fast and high index of suspicion is the key to success, from the initial assessment to the final rehabilitation of the cases, from the victim of risk factors to the victims of situation. The research groups feel that TBI prophylactic measures and primary care mitigation models are as important as definitive care, starting from prehospital care to dedicated care.
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Affiliation(s)
- Subhas Konar
- Department of Neurosurgery, National Institute of Mental Health and Neuro-Sciences, Bengaluru, Karnataka, India
| | - Orlin Pavlov
- Department of Neurosurgery, Fulda Clinic, Fulda, Germany
| | - Yeider Durango-Espinosa
- Department of Neurosurgery, Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Ezequiel Garcia-Ballestas
- Department of Neurosurgery, Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
| | - Andrei Fernandes Joaquim
- Division of Neurosurgery, Department of Neurology, University of Campinas (UNICAMP), Campinas, São Paulo, Brazil
| | - Amrita Ghosh
- Department of Biochemistry, Medical College, Kolkata, West Bengal, India
| | - Ranabir Pal
- Department of Community Medicine, Mata Gujri Memorial Medical College & Lion Seva Kendra Hospital, Kishanganj, Bihar, India
| | - Luis Rafael Moscote-Salazar
- Department of Neurosurgery, Center for Biomedical Research (CIB), Faculty of Medicine, University of Cartagena, Cartagena, Colombia
- Department of Neurosurgery, Paracelus Medical University, Salzburg, Austria
| | - Amit Agrawal
- Department of Neurosurgery, All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India
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15
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Ho HH, Nguyen AT, Chen YC, Chen LY, Dang HP, Tsai MJ, Cheng H, Horng SF, Huang CS, Zan HW, Meng HF. A Cylindrical Ion Sensor Tip with a Diameter of 1.5 mm for Potentially Invasive Medical Application. ACS OMEGA 2020; 5:23021-23027. [PMID: 32954152 PMCID: PMC7495754 DOI: 10.1021/acsomega.0c02725] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Figures] [Subscribe] [Scholar Register] [Received: 06/10/2020] [Accepted: 08/19/2020] [Indexed: 06/11/2023]
Abstract
A fine cylindrical chemical sensor tip is developed with optical fiber in the core, surrounded by a transparent cylinder of photopolymer Norland Optical Adhesive 61 (NOA 61), and covered by a polymer hydrogel mixed with sensing molecules. The overall diameter is as small as 1.5 mm. pH response is demonstrated using two approaches of sensing materials: (i) absorbing probe Phenol Red mixed with Rhodamine 6G fluorescent dye and (ii) 8-hydroxypyrene-1,3,6-trisulfonic acid fluorescent probe. Both the optical excitation and fluorescence signal collection are through the optical fibers. A time resolution of 10 s is achieved for pH variations. Good linearity is observed in the physiological range from pH 7.0 to pH 8.6 with reversible and reproducible outcomes. For in vitro urea measurement, the sensor tip can distinguish 1, 3, and 5 mM urea solution, which is a crucial range in saliva urea concentration. The miniaturized tip with such simple cylindrical symmetry is designed to detect vital signs during minimally invasive surgeries and can be potentially accompanied with endoscopes to enter human bodies.
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Affiliation(s)
- Hsin-Hsien Ho
- Institute
of Electronic Engineering, National Tsing
Hua University, Hsinchu 300, Taiwan
| | - Anh-Thi Nguyen
- Institute
of Physics, National Chiao Tung University, Hsinchu 300, Taiwan
| | - Yen-Chi Chen
- Department
of Mechanical Engineering, National Chiao
Tung University, Hsinchu 300, Taiwan
| | - Li-Yin Chen
- Department
of Photonics, College of Electrical and Computer Engineering, National Chiao Tung University, Hsinchu 300, Taiwan
| | - Huu-Phuoc Dang
- Institute
of Physics, National Chiao Tung University, Hsinchu 300, Taiwan
| | - May-Jywan Tsai
- Department
of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Henrich Cheng
- Department
of Neurosurgery, Neurological Institute, Taipei Veterans General Hospital, Taipei 11217, Taiwan
| | - Sheng-Fu Horng
- Institute
of Electronic Engineering, National Tsing
Hua University, Hsinchu 300, Taiwan
| | - Cheng-Sheng Huang
- Department
of Mechanical Engineering, National Chiao
Tung University, Hsinchu 300, Taiwan
| | - Hsiao-Wen Zan
- Department
of Photonics, College of Electrical and Computer Engineering, National Chiao Tung University, Hsinchu 300, Taiwan
| | - Hsin-Fei Meng
- Institute
of Physics, National Chiao Tung University, Hsinchu 300, Taiwan
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16
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Enrichi C, Zanetti C, Stabile R, Carollo C, Ghezzo L, Piccione F. Use of ventilation bag for the respiratory support during magnetic resonance imaging in Arnold-Chiari ventilated patients, a case report. J Spinal Cord Med 2020; 43:710-713. [PMID: 30207874 PMCID: PMC7534381 DOI: 10.1080/10790268.2018.1519997] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/28/2022] Open
Abstract
Context: Magnetic Resonance Imaging (MRI) is an essential diagnostic tool for neuroimaging tissues such as the spinal cord. Unfortunately, the use of MRI may be limited in ventilated patients, who cannot maintain the supine position in spontaneous breathing for the whole duration of the exam (i.e. neuro-muscular patients with diaphragm involvement). The use of MRI-compatible ventilator during MRI could be a solution but they are not universally available. Furthermore, their performances are not up to those of the conventional ones and they are not always compatible with Non Invasive Ventilation (NIV). Findings: This case report describes an easy and low-cost solution to ventilate a patient non-invasively during the MRI procedure. The patient in this case was a 45-yr-old man, wheelchair-dependent and chronically ventilated in NIV with a forced vital capacity in supine position of 370 ml (10% of predicted normal), affected by Arnold-Chiari Syndrome, and in need of a MRI diagnostic control. Conclusion: The technique proposed, that does not affect the MRI images quality, consists in ventilating the patient using a simple nonmetallic Ventilation Bag, operated by a Respiratory Therapist. This has been proven a useful and economical solution for ventilatory support during MRI for a respiratory-dependent patient with Arnold-Chiari Syndrome.
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Affiliation(s)
- Claudia Enrichi
- Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Venezia, Italia,Correspondence to: Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Via Alberoni 70, Lido di Venezia, Venice, Italy; Ph: +39 3409819774.
| | - Cristiano Zanetti
- Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Venezia, Italia
| | - Rosaria Stabile
- Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Venezia, Italia
| | - Carla Carollo
- Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Venezia, Italia
| | - Luca Ghezzo
- Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Venezia, Italia
| | - Francesco Piccione
- Neurorehabilitation Department, Fondazione Ospedale San Camillo IRCCS, Venezia, Italia
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17
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Cerebral Energy Status and Altered Metabolism in Early Severe TBI: First Results of a Prospective 31P-MRS Feasibility Study. Neurocrit Care 2020; 34:432-440. [PMID: 32617851 DOI: 10.1007/s12028-020-01042-x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
Abstract
OBJECTIVE Severe traumatic brain injury (sTBI) represents a serious public health issue with high morbidity and mortality. Neuroimaging plays a crucial role in the evaluation of sTBI patients. Phosphorous magnetic resonance spectroscopy (31P-MRS) is an imaging technique for evaluation of energy metabolites. The aim of this study is to evaluate the feasibility and the diagnostic potential of ultra-early 31P-MRS to detect changes in cerebral energy metabolism in sTBI. METHODS Adult patients with sTBI presenting with GCS ≤ 8 being eligible for MRI were prospectively included in the study and MRI was performed within 72 h after trauma. Imaging was performed using a 3 Tesla MRI. 31P-MRS data from the structurally affected side were compared to data from normal appearing contralateral areas symmetrically to the location of the traumatic lesions, and to data of matched healthy controls. RESULTS Ten sTBI patients (3 female, 7 male), aged between 20 and 75 years, with a mean initial GCS of 6 were analyzed. MRI was performed 61 h (mean, range 37-71 h) after trauma. Statistical analysis revealed no significant differences between the lesioned side and contralaterally. An increased PCr/ATP ratio and a decreased PME/PDE ratio were present in structurally normal appearing, but traumatized tissue when compared to the healthy population, thus indicating significant differences in ATP resynthesis and membrane turnover (F (2,33), P = 0.005 and, P = 0.027, respectively). CONCLUSION 31P-MRS could provide a better understanding of pertinent global changes in cerebral energy metabolism in sTBI patients under general anesthesia.
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18
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Ghaly RF, Haroutanian A, Khamooshi P, Patricoski J, Candido KD, Knezevic NN. Recent decline in the use of invasive neurocritical care monitoring for traumatic brain injury: A case report. Surg Neurol Int 2020; 11:85. [PMID: 32363076 PMCID: PMC7193652 DOI: 10.25259/sni_65_2020] [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: 02/19/2020] [Accepted: 04/01/2020] [Indexed: 11/25/2022] Open
Abstract
Background: In this article, we discuss the dramatic decline in the utilization of invasive cranial monitoring of patients with traumatic brain injury (TBI). Case Description: A 52-year-old male presented with a severe TBI following a motor vehicle accident. The initial computed tomography scan showed a subdural hematoma, and the patient underwent a craniotomy. However, preoperatively, intraoperatively, and postoperatively, the critical care team never utilized invasive cranial monitoring. Therefore, when the patient expired several weeks later due to multiorgan failure, his death was in part attributed to the neurocritical care specialists’ failure to employ invasive cranial monitoring techniques. Conclusion: Evidence-based and defensive medicine, cost containment, and a lack of leadership have contributed to neurocritical care specialists’ increased failure to utilize invasive hemodynamic and neurological monitoring for TBI.
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Affiliation(s)
- Ramsis F Ghaly
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, United States.,Ghaly Neurosurgical Associates, Aurora, United States.,Department of Anesthesiology, University of Illinois, Chicago, Illinois, United States
| | - Armen Haroutanian
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, United States
| | - Parnia Khamooshi
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, United States
| | | | - Kenneth D Candido
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, United States.,Department of Anesthesiology, University of Illinois, Chicago, Illinois, United States
| | - Nebojsa Nick Knezevic
- Department of Anesthesiology, Advocate Illinois Masonic Medical Center, Chicago, United States.,Department of Anesthesiology, University of Illinois, Chicago, Illinois, United States
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19
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Kurtz P, Rocha EEM. Nutrition Therapy, Glucose Control, and Brain Metabolism in Traumatic Brain Injury: A Multimodal Monitoring Approach. Front Neurosci 2020; 14:190. [PMID: 32265626 PMCID: PMC7105880 DOI: 10.3389/fnins.2020.00190] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/05/2019] [Accepted: 02/21/2020] [Indexed: 12/19/2022] Open
Abstract
The goal of neurocritical care in patients with traumatic brain injury (TBI) is to prevent secondary brain damage. Pathophysiological mechanisms lead to loss of body mass, negative nitrogen balance, dysglycemia, and cerebral metabolic dysfunction. All of these complications have been shown to impact outcomes. Therapeutic options are available that prevent or mitigate their negative impact. Nutrition therapy, glucose control, and multimodality monitoring with cerebral microdialysis (CMD) can be applied as an integrated approach to optimize systemic immune and organ function as well as adequate substrate delivery to the brain. CMD allows real-time bedside monitoring of aspects of brain energy metabolism, by measuring specific metabolites in the extracellular fluid of brain tissue. Sequential monitoring of brain glucose and lactate/pyruvate ratio may reveal pathologic processes that lead to imbalances in supply and demand. Early recognition of these patterns may help individualize cerebral perfusion targets and systemic glucose control following TBI. In this direction, recent consensus statements have provided guidelines and recommendations for CMD applications in neurocritical care. In this review, we summarize data from clinical research on patients with severe TBI focused on a multimodal approach to evaluate aspects of nutrition therapy, such as timing and route; aspects of systemic glucose management, such as intensive vs. moderate control; and finally, aspects of cerebral metabolism. Research and clinical applications of CMD to better understand the interplay between substrate supply, glycemic variations, insulin therapy, and their effects on the brain metabolic profile were also reviewed. Novel mechanistic hypotheses in the interpretation of brain biomarkers were also discussed. Finally, we offer an integrated approach that includes nutritional and brain metabolic monitoring to manage severe TBI patients.
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Affiliation(s)
- Pedro Kurtz
- Department of Neurointensive Care, Instituto Estadual do Cérebro Paulo Niemeyer, Rio de Janeiro, Brazil.,Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
| | - Eduardo E M Rocha
- Department of Intensive Care Medicine, Hospital Copa Star, Rio de Janeiro, Brazil
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20
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Wu C, Xu J, Jin X, Chen Q, Lu X, Qian A, Wang M, Li Z, Zhang M. Effects of therapeutic hypothermia on cerebral tissue oxygen saturation in a swine model of post-cardiac arrest. Exp Ther Med 2020; 19:1189-1196. [PMID: 32010288 PMCID: PMC6966162 DOI: 10.3892/etm.2019.8316] [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: 03/19/2019] [Accepted: 11/01/2019] [Indexed: 11/08/2022] Open
Abstract
Since the introduction of therapeutic hypothermia (TH), trends have changed in the monitoring indicators used during and after cardiac arrest. During hypothermia, the cerebral metabolic rate of oxygen is reduced, which leads to uncertainty in regional cerebral tissue oxygen saturation (SctO2). The aim of the present study was to evaluate the effect of TH on changes in SctO2 using near-infrared spectroscopy. A total of 23 male domestic pigs were randomized into three groups: TH (n=9), normothermia (NT; n=9) and control (n=5). Animals in the control group underwent surgical preparation only. The animal models were established using 8 min of ventricular fibrillation and 5 min of cardiopulmonary resuscitation. In the TH group, at 5 min after resuscitation, the animals were cooled with a cooling blanket and ice packs for 24 h. SctO2 was recorded throughout the experiment. In all groups, The mean arterial pressure, arterial carbon dioxide partial pressure, arterial oxygen partial pressure, lactate, neuron-specific enolase (NSE) and S100B were measured at baseline and at 1, 3, 6, 12, 24 and 30 h after resuscitation. SctO2 significantly decreased after ventricular fibrillation, compared with the baseline. Following resuscitation, the SctO2 values gradually increased to 55.6±3.8% of baseline in the TH group and 51.2±3.5% in the NT group (P=0.039). Significant differences between the two groups were observed, starting at 6 h after cardiac arrest. Throughout the hypothermic period, NSE and S100B showed an increasing trend, then decreased during rewarming in the TH and NT groups. NSE and S100B showed greater improvement in the TH group compared with the NT group at 6 and 24 h after resuscitation. Following cardiac arrest, therapeutic hypothermia could increase SctO2 after resuscitation and could improve neurological outcome. In conclusion, SctO2 may be a feasible marker for use in the early assessment of brain damage during and after cardiac arrest.
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Affiliation(s)
- Chunshuang Wu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Jiefeng Xu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China.,Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, Zhejiang 315400, P.R. China
| | - Xiaohong Jin
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China.,Department of Emergency Medicine, Wenling People's Hospital, Taizhou, Zhejiang 317500, P.R. China
| | - Qijiang Chen
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China.,Department of Emergency Medicine, Ninghai People's Hospital, Ningbo, Zhejiang 315500, P.R. China
| | - Xiao Lu
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Anyu Qian
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
| | - Moli Wang
- Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, Zhejiang 315400, P.R. China
| | - Zilong Li
- Department of Emergency Medicine, Yuyao People's Hospital, Ningbo, Zhejiang 315400, P.R. China
| | - Mao Zhang
- Department of Emergency Medicine, Second Affiliated Hospital, Zhejiang University School of Medicine and Institute of Emergency Medicine, Zhejiang University, Hangzhou, Zhejiang 310009, P.R. China
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21
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Management of Head Trauma in the Neurocritical Care Unit. Neurocrit Care 2019. [DOI: 10.1017/9781107587908.017] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/07/2022]
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Nag DS, Sahu S, Swain A, Kant S. Intracranial pressure monitoring: Gold standard and recent innovations. World J Clin Cases 2019; 7:1535-1553. [PMID: 31367614 PMCID: PMC6658373 DOI: 10.12998/wjcc.v7.i13.1535] [Citation(s) in RCA: 124] [Impact Index Per Article: 20.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/04/2019] [Revised: 05/11/2019] [Accepted: 05/23/2019] [Indexed: 02/05/2023] Open
Abstract
Intracranial pressure monitoring (ICP) is based on the doctrine proposed by Monroe and Kellie centuries ago. With the advancement of technology and science, various invasive and non-invasive modalities of monitoring ICP continue to be developed. An ideal monitor to track ICP should be easy to use, accurate, reliable, reproducible, inexpensive and should not be associated with infection or haemorrhagic complications. Although the transducers connected to the extra ventricular drainage continue to be Gold Standard, its association with the likelihood of infection and haemorrhage have led to the search for alternate non-invasive methods of monitoring ICP. While Camino transducers, Strain gauge micro transducer based ICP monitoring devices and the Spiegelberg ICP monitor are the emerging technology in invasive ICP monitoring, optic nerve sheath diameter measurement, venous opthalmodynamometry, tympanic membrane displacement, tissue resonance analysis, tonometry, acoustoelasticity, distortion-product oto-acoustic emissions, trans cranial doppler, electro encephalogram, near infra-red spectroscopy, pupillometry, anterior fontanelle pressure monitoring, skull elasticity, jugular bulb monitoring, visual evoked response and radiological based assessment of ICP are the non-invasive methods which are assessed against the gold standard.
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Affiliation(s)
- Deb Sanjay Nag
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Seelora Sahu
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Amlan Swain
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
| | - Shashi Kant
- Department of Anaesthesiology and Critical Care, Tata Main Hospital, Jamshedpur 831001, India
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23
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Agoston DV, Vink R, Helmy A, Risling M, Nelson D, Prins M. How to Translate Time: The Temporal Aspects of Rodent and Human Pathobiological Processes in Traumatic Brain Injury. J Neurotrauma 2019; 36:1724-1737. [PMID: 30628544 PMCID: PMC7643768 DOI: 10.1089/neu.2018.6261] [Citation(s) in RCA: 30] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/18/2022] Open
Abstract
Traumatic brain injury (TBI) triggers multiple pathobiological responses with differing onsets, magnitudes, and durations. Identifying the therapeutic window of individual pathologies is critical for successful pharmacological treatment. Dozens of experimental pharmacotherapies have been successfully tested in rodent models, yet all of them (to date) have failed in clinical trials. The differing time scales of rodent and human biological and pathological processes may have contributed to these failures. We compared rodent versus human time scales of TBI-induced changes in cerebral glucose metabolism, inflammatory processes, axonal integrity, and water homeostasis based on published data. We found that the trajectories of these pathologies run on different timescales in the two species, and it appears that there is no universal "conversion rate" between rodent and human pathophysiological processes. For example, the inflammatory process appears to have an abbreviated time scale in rodents versus humans relative to cerebral glucose metabolism or axonal pathologies. Limitations toward determining conversion rates for various pathobiological processes include the use of differing outcome measures in experimental and clinical TBI studies and the rarity of longitudinal studies. In order to better translate time and close the translational gap, we suggest 1) using clinically relevant outcome measures, primarily in vivo imaging and blood-based proteomics, in experimental TBI studies and 2) collecting data at multiple post-injury time points with a frequency exceeding the expected information content by two or three times. Combined with a big data approach, we believe these measures will facilitate the translation of promising experimental treatments into clinical use.
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Affiliation(s)
- Denes V. Agoston
- Department of Anatomy, Physiology and Genetics, Uniformed Services University, Bethesda, Maryland
| | - Robert Vink
- Division of Health Science, University of South Australia, Adelaide, Australia
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neuroscience, University of Cambridge, Cambridge, United Kingdom
| | - Mårten Risling
- Department of Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - David Nelson
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Mayumi Prins
- Department of Neurosurgery, David Geffen School of Medicine, University of California, Los Angeles, California
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Is artificial intelligence (AI) at the doorstep of Intensive Care Units (ICU) and operating room (OR)? Anaesth Crit Care Pain Med 2019; 38:337-338. [PMID: 31102792 DOI: 10.1016/j.accpm.2019.05.003] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/28/2023]
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Abstract
Neuromonitoring is important for patients with acute brain injury. The bedside neurologic examination is standard for neurologic monitoring; however, a clinical examination may not reliably detect subtle changes in intracranial physiology. Changes found during neurologic examinations are often late signs. The assessment of multiple physiological variables in real time can provide new clinical insights into treatment decisions. No single monitoring modality is ideal for all patients. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism, such as in multimodal monitoring, allows an innovative approach to individualized patient care.
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Affiliation(s)
- Sarah H Peacock
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
| | - Amanda D Tomlinson
- Sarah H. Peacock is Acute Care Nurse Practitioner, Department of Critical Care Medicine, Instructor of Medicine, College of Medicine, Mayo Clinic, 4500 San Pablo Rd, Jacksonville, FL 32224 . Amanda D. Tomlinson is Acute Nurse Practitioner, Department of Critical Care Medicine, Instructor of Neurology, College of Medicine, Mayo Clinic, Jacksonville, Florida
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26
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Godoy DA, Lubillo S, Rabinstein AA. Pathophysiology and Management of Intracranial Hypertension and Tissular Brain Hypoxia After Severe Traumatic Brain Injury: An Integrative Approach. Neurosurg Clin N Am 2018; 29:195-212. [PMID: 29502711 DOI: 10.1016/j.nec.2017.12.001] [Citation(s) in RCA: 37] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Monitoring intracranial pressure in comatose patients with severe traumatic brain injury (TBI) is considered necessary by most experts. Acute intracranial hypertension (IHT), when severe and sustained, is a life-threatening complication that demands emergency treatment. Yet, secondary anoxic-ischemic injury after brain trauma can occur in the absence of IHT. In such cases, adding other monitoring modalities can alert clinicians when the patient is in a state of energy failure. This article reviews the mechanisms, diagnosis, and treatment of IHT and brain hypoxia after TBI, emphasizing the need to develop a physiologically integrative approach to the management of these complex situations.
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Affiliation(s)
- Daniel Agustín Godoy
- Intensive Care Unit, San Juan Bautista Hospital, Catamarca, Argentina; Neurointensive Care Unit, Sanatorio Pasteur, Catamarca, Argentina.
| | - Santiago Lubillo
- Intensive Care Unit, Hospital Universitario NS de Candelaria, Tenerife, Spain
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27
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Kim W, Taw B, Yokosako S, Koyanagi M, Fukuda H, Sinclair D, Sirhan D, Teitelbaum J, Lui MW, Kasuya H, Angle M, Lo BW. The future of non-invasive cerebral oximetry in neurosurgical procedures: A systematic review. ACTA ACUST UNITED AC 2018. [DOI: 10.12688/mniopenres.12779.1] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/20/2023]
Abstract
Background:Cerebral hypoxia is one of the most important causes of secondary brain injury during neurosurgical procedures and in neurointensive care. In patients with brain injury, cerebrovascular reactivity may be impaired and a decrease in mean arterial pressure or cerebral perfusion pressure may lead to inadequate cerebral blood flow and secondary ischemia. There are several techniques available to measure brain oxygenation. In particular, near infrared spectroscopy (NIRS) is a non-invasive neuromonitoring technique and there has been a rapid expansion of clinical evidence that NIRS reduces perioperative neurologic complications. Methods:This systematic review synthesizes prospective and retrospective cohort studies that investigate the benefit of using NIRS in prevention of perioperative neurologic complications. The methodological quality of these studies is appraised.Results:Seven studies were included in this systematic review. The methodological quality of each study was assessed. They had representative patient populations, clear selection criteria and clear descriptions of study designs. Reproducible study protocols with ethics board approval were present. Clinical results were described in sufficient detail and were applicable to patient undergoing neurosurgical procedures and in neurointensive care. Limitations included small sample sizes and lack of reference standard.Conclusions:This systematic review synthesizes the most current evidence of non-invasive, inexpensive, and continuous measurement of cerebral oxygenation by NIRS. Results gained from these studies are clinically useful and shed light on how this neuromonitoring technique is beneficial in preventing perioperative neurological complications.
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28
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Xu Z, Liu Z, Zhang Y, Jin C, Shen F, Yu Y, Cheek T, Onuoha O, Liang G, Month R, Atkins J, Tran KM, Wei H. S100β in newborns after C-section with general vs. epidural anesthesia: a prospective observational study. Acta Anaesthesiol Scand 2018; 62:293-303. [PMID: 29159929 DOI: 10.1111/aas.13038] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2017] [Revised: 07/18/2017] [Accepted: 10/23/2017] [Indexed: 11/30/2022]
Abstract
BACKGROUND Preclinical evidence suggests that general anesthetics can dose dependently induce neurodegeneration in the developing brains of animals which can be reliably determined by measurement of blood S100β, but this correlation remains unclear in humans. We hypothesized that S100β would not be increased in cord arterial blood of fetuses exposed briefly to general anesthetics during a C-section, compared with epidural anesthesia. METHODS A prospective observational clinical study comparatively measured changes of brain damage biomarker S100β ratio of umbilical artery over vein (changes after fetus circulation) immediately after delivery under C-section with either epidural or general anesthesia. Newborn blood gas measurements, APGAR scores, and maternal well-being were also compared. RESULTS Compared with epidural anesthesia, general anesthesia resulted in the lower S100β ratio of umbilical artery over the vein (medium 2.64 [quartiles 1.39, 3.45] vs. medium 1.59 [quartiles 0.88, 2.01], P = 0.031), without changing the S100β level in the vein of the mother. There was no significant difference between general and epidural anesthesia when comparing other maternal and newborn parameters. CONCLUSION S100β levels in newborn after C-section is lower with general anesthesia than epidural anesthesia, with unclear mechanisms.
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Affiliation(s)
- Z. Xu
- Department of Anesthesiology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Z. Liu
- Department of Anesthesiology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Y. Zhang
- Department of Anesthesiology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - C. Jin
- Department of Anesthesiology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - F. Shen
- Department of Anesthesiology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - Y. Yu
- Department of Anesthesiology; Shanghai First Maternity and Infant Hospital; Tongji University School of Medicine; Shanghai China
| | - T. Cheek
- Department of Anesthesiology and Critical Care; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - O. Onuoha
- Department of Anesthesiology and Critical Care; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - G. Liang
- Department of Anesthesiology and Critical Care; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - R. Month
- Department of Anesthesiology and Critical Care; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - J. Atkins
- Department of Anesthesiology and Critical Care; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
| | - K. M. Tran
- Department of Anesthesiology and Critical Care; Children Hospital of Philadelphia; Philadelphia PA USA
| | - H. Wei
- Department of Anesthesiology and Critical Care; Perelman School of Medicine; University of Pennsylvania; Philadelphia PA USA
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29
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Godoy DA, Videtta W, Di Napoli M. Practical Approach to Posttraumatic Intracranial Hypertension According to Pathophysiologic Reasoning. Neurol Clin 2017; 35:613-640. [DOI: 10.1016/j.ncl.2017.06.002] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023]
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30
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Stone JL, Bailes JE, Hassan AN, Sindelar B, Patel V, Fino J. Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring. Neurocrit Care 2017; 26:143-156. [PMID: 27484878 DOI: 10.1007/s12028-016-0298-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.
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Affiliation(s)
- James L Stone
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA. .,Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA. .,Division of Neurosurgery, Department of Surgery, Cook County Stroger Hospital, Chicago, IL, USA.
| | - Julian E Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Ahmed N Hassan
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Brian Sindelar
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.,Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Vimal Patel
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - John Fino
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
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31
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Sivakumar S, Taccone FS, Rehman M, Hinson H, Naval N, Lazaridis C. Hemodynamic and neuro-monitoring for neurocritically ill patients: An international survey of intensivists. J Crit Care 2017; 39:40-47. [DOI: 10.1016/j.jcrc.2017.01.005] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2016] [Accepted: 01/14/2017] [Indexed: 11/29/2022]
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32
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Dreier JP, Fabricius M, Ayata C, Sakowitz OW, William Shuttleworth C, Dohmen C, Graf R, Vajkoczy P, Helbok R, Suzuki M, Schiefecker AJ, Major S, Winkler MKL, Kang EJ, Milakara D, Oliveira-Ferreira AI, Reiffurth C, Revankar GS, Sugimoto K, Dengler NF, Hecht N, Foreman B, Feyen B, Kondziella D, Friberg CK, Piilgaard H, Rosenthal ES, Westover MB, Maslarova A, Santos E, Hertle D, Sánchez-Porras R, Jewell SL, Balança B, Platz J, Hinzman JM, Lückl J, Schoknecht K, Schöll M, Drenckhahn C, Feuerstein D, Eriksen N, Horst V, Bretz JS, Jahnke P, Scheel M, Bohner G, Rostrup E, Pakkenberg B, Heinemann U, Claassen J, Carlson AP, Kowoll CM, Lublinsky S, Chassidim Y, Shelef I, Friedman A, Brinker G, Reiner M, Kirov SA, Andrew RD, Farkas E, Güresir E, Vatter H, Chung LS, Brennan KC, Lieutaud T, Marinesco S, Maas AIR, Sahuquillo J, Dahlem MA, Richter F, Herreras O, Boutelle MG, Okonkwo DO, Bullock MR, Witte OW, Martus P, van den Maagdenberg AMJM, Ferrari MD, Dijkhuizen RM, Shutter LA, Andaluz N, Schulte AP, MacVicar B, Watanabe T, Woitzik J, Lauritzen M, Strong AJ, Hartings JA. Recording, analysis, and interpretation of spreading depolarizations in neurointensive care: Review and recommendations of the COSBID research group. J Cereb Blood Flow Metab 2017; 37:1595-1625. [PMID: 27317657 PMCID: PMC5435289 DOI: 10.1177/0271678x16654496] [Citation(s) in RCA: 255] [Impact Index Per Article: 31.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/20/2016] [Revised: 05/04/2016] [Accepted: 05/06/2016] [Indexed: 01/18/2023]
Abstract
Spreading depolarizations (SD) are waves of abrupt, near-complete breakdown of neuronal transmembrane ion gradients, are the largest possible pathophysiologic disruption of viable cerebral gray matter, and are a crucial mechanism of lesion development. Spreading depolarizations are increasingly recorded during multimodal neuromonitoring in neurocritical care as a causal biomarker providing a diagnostic summary measure of metabolic failure and excitotoxic injury. Focal ischemia causes spreading depolarization within minutes. Further spreading depolarizations arise for hours to days due to energy supply-demand mismatch in viable tissue. Spreading depolarizations exacerbate neuronal injury through prolonged ionic breakdown and spreading depolarization-related hypoperfusion (spreading ischemia). Local duration of the depolarization indicates local tissue energy status and risk of injury. Regional electrocorticographic monitoring affords even remote detection of injury because spreading depolarizations propagate widely from ischemic or metabolically stressed zones; characteristic patterns, including temporal clusters of spreading depolarizations and persistent depression of spontaneous cortical activity, can be recognized and quantified. Here, we describe the experimental basis for interpreting these patterns and illustrate their translation to human disease. We further provide consensus recommendations for electrocorticographic methods to record, classify, and score spreading depolarizations and associated spreading depressions. These methods offer distinct advantages over other neuromonitoring modalities and allow for future refinement through less invasive and more automated approaches.
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Affiliation(s)
- Jens P Dreier
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Fabricius
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Cenk Ayata
- Neurovascular Research Laboratory, Department of Radiology, and Stroke Service and Neuroscience Intensive Care Unit, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Oliver W Sakowitz
- Department of Neurosurgery, Klinikum Ludwigsburg, Ludwigsburg, Germany
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - C William Shuttleworth
- Department of Neurosciences, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christian Dohmen
- Department of Neurology, University of Cologne, Cologne, Germany
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Rudolf Graf
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Peter Vajkoczy
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Raimund Helbok
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Michiyasu Suzuki
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Alois J Schiefecker
- Department of Neurology, Neurocritical Care Unit, Medical University Innsbruck, Innsbruck, Austria
| | - Sebastian Major
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurology, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Maren KL Winkler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Eun-Jeung Kang
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Denny Milakara
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Ana I Oliveira-Ferreira
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Clemens Reiffurth
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
| | - Gajanan S Revankar
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Kazutaka Sugimoto
- Department of Neurosurgery, Yamaguchi University Graduate School of Medicine, Ube, Yamaguchi, Japan
| | - Nora F Dengler
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Nils Hecht
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, Neurocritical Care Division, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Bart Feyen
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | | | | | - Henning Piilgaard
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
| | - Eric S Rosenthal
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - M Brandon Westover
- Department of Neurology, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA
| | - Anna Maslarova
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Edgar Santos
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | - Daniel Hertle
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
| | | | - Sharon L Jewell
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Baptiste Balança
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- Université Claude Bernard, Lyon, France
| | - Johannes Platz
- Department of Neurosurgery, Goethe-University, Frankfurt, Germany
| | - Jason M Hinzman
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Janos Lückl
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
| | - Karl Schoknecht
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Experimental Neurology, Charité University Medicine Berlin, Berlin, Germany
- Neuroscience Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Schöll
- Department of Neurosurgery, University Hospital, Heidelberg, Germany
- Institute of Medical Biometry and Informatics, University of Heidelberg, Heidelberg, Germany
| | - Christoph Drenckhahn
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Neurological Center, Segeberger Kliniken, Bad Segeberg, Germany
| | - Delphine Feuerstein
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Nina Eriksen
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital, Rigshospitalet, Copenhagen, Denmark
| | - Viktor Horst
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Julia S Bretz
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Paul Jahnke
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Michael Scheel
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Georg Bohner
- Department of Neuroradiology, Charité University Medicine Berlin, Berlin, Germany
| | - Egill Rostrup
- Department of Clinical Physiology and Nuclear Medicine, Rigshospitalet, Copenhagen, Denmark
| | - Bente Pakkenberg
- Research Laboratory for Stereology and Neuroscience, Bispebjerg-Frederiksberg Hospital, Rigshospitalet, Copenhagen, Denmark
- Faculty of Health and Medical Sciences, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Uwe Heinemann
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Neuroscience Research Center, Charité University Medicine Berlin, Berlin, Germany
| | - Jan Claassen
- Neurocritical Care, Columbia University College of Physicians & Surgeons, New York, NY, USA
| | - Andrew P Carlson
- Department of Neurosurgery, University of New Mexico School of Medicine, Albuquerque, NM, USA
| | - Christina M Kowoll
- Department of Neurology, University of Cologne, Cologne, Germany
- Multimodal Imaging of Brain Metabolism, Max-Planck-Institute for Metabolism Research, Cologne, Germany
| | - Svetlana Lublinsky
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Yoash Chassidim
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Ilan Shelef
- Department of Neuroradiology, Soroka University Medical Center and Zlotowski Center for Neuroscience, Ben-Gurion University of the Negev, Beer-Sheva, Israel
| | - Alon Friedman
- Department of Physiology and Cell Biology, Zlotowski Center for Neuroscience, Beer-Sheva, Israel
- Department of Medical Neuroscience, Faculty of Medicine, Dalhousie University, Halifax, Canada
| | - Gerrit Brinker
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Michael Reiner
- Department of Neurosurgery, University of Cologne, Cologne, Germany
| | - Sergei A Kirov
- Department of Neurosurgery and Brain and Behavior Discovery Institute, Medical College of Georgia, Augusta, GA, USA
| | - R David Andrew
- Department of Biomedical & Molecular Sciences, Queen’s University, Kingston, Canada
| | - Eszter Farkas
- Department of Medical Physics and Informatics, Faculty of Medicine, and Faculty of Science and Informatics, University of Szeged, Szeged, Hungary
| | - Erdem Güresir
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Hartmut Vatter
- Department of Neurosurgery, University Hospital and University of Bonn, Bonn, Germany
| | - Lee S Chung
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - KC Brennan
- Department of Neurology, University of Utah, Salt Lake City, UT, USA
| | - Thomas Lieutaud
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- Université Claude Bernard, Lyon, France
| | - Stephane Marinesco
- Inserm U10128, CNRS UMR5292, Lyon Neuroscience Research Center, Team TIGER, Lyon, France
- AniRA-Neurochem Technological Platform, Lyon, France
| | - Andrew IR Maas
- Department of Neurosurgery, Antwerp University Hospital and University of Antwerp, Edegem, Belgium
| | - Juan Sahuquillo
- Department of Neurosurgery, Neurotraumatology and Neurosurgery Research Unit (UNINN), Vall d’Hebron University Hospital, Universitat Autònoma de Barcelona, Barcelona, Spain
| | | | - Frank Richter
- Institute of Physiology I/Neurophysiology, Friedrich Schiller University Jena, Jena, Germany
| | - Oscar Herreras
- Department of Systems Neuroscience, Cajal Institute-CSIC, Madrid, Spain
| | | | - David O Okonkwo
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - M Ross Bullock
- Department of Neurological Surgery, University of Miami, Miami, FL, USA
| | - Otto W Witte
- Hans Berger Department of Neurology, Jena University Hospital, Friedrich Schiller University Jena, Jena, Germany
| | - Peter Martus
- Institute for Clinical Epidemiology and Applied Biometry, University of Tübingen, Tübingen, Germany
| | - Arn MJM van den Maagdenberg
- Department of Human Genetics, Leiden University Medical Center, Leiden, the Netherlands
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Michel D Ferrari
- Department of Neurology, Leiden University Medical Center, Leiden, the Netherlands
| | - Rick M Dijkhuizen
- Center for Image Sciences, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Lori A Shutter
- Department of Neurosurgery, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
- Department of Critical Care Medicine and Neurology, University of Pittsburgh Medical Center, Pittsburgh, PA, USA
| | - Norberto Andaluz
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
| | - André P Schulte
- Department of Spinal Surgery, St. Franziskus Hospital Cologne, Cologne, Germany
| | - Brian MacVicar
- Department of Psychiatry, University of British Columbia, Vancouver, Canada
| | | | - Johannes Woitzik
- Center for Stroke Research Berlin, Charité University Medicine Berlin, Berlin, Germany
- Department of Neurosurgery, Charité University Medicine Berlin, Berlin, Germany
| | - Martin Lauritzen
- Department of Clinical Neurophysiology, Rigshospitalet, Copenhagen, Denmark
- Department of Neuroscience and Pharmacology, Panum Institute, University of Copenhagen, Copenhagen, Denmark
| | - Anthony J Strong
- Department of Basic and Clinical Neuroscience, Institute of Psychiatry, Psychology and Neuroscience, King’s College London, London, UK
| | - Jed A Hartings
- Department of Neurosurgery, University of Cincinnati College of Medicine, Cincinnati, OH, USA
- Mayfield Clinic, Cincinnati, OH, USA
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Neurophysiological assessment of brain dysfunction in critically ill patients: an update. Neurol Sci 2017; 38:715-726. [PMID: 28110410 DOI: 10.1007/s10072-017-2824-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/16/2017] [Indexed: 01/08/2023]
Abstract
The aim of this review was to provide up-to-date information about the usefulness of clinical neurophysiology testing in the management of critically ill patients. Evoked potentials (EPs) and electroencephalogram (EEG) are non-invasive clinical neurophysiology tools that allow an objective assessment of the central nervous system's function at the bedside in intensive care unit (ICU). These tests are quite useful in diagnosing cerebral complications, and establishing the vital and functional prognosis in ICU. EEG keeps a particularly privileged importance in detecting seizures phenomena such as subclinical seizures and non-convulsive status epilepticus. Quantitative EEG (QEEG) analysis techniques commonly called EEG Brain mapping can provide obvious topographic displays of digital EEG signals characteristics, showing the potential distribution over the entire scalp including filtering, frequency, and amplitude analysis and color mapping. Evidences of usefulness of QEEG for seizures detection in ICU are provided by several recent studies. Furthermore, beyond detection of epileptic phenomena, changes of some QEEG panels are early warning indicators of sedation level as well as brain damage or dysfunction in ICU. EPs offer the opportunity for assessing brainstem's functional integrity, as well as subcortical and cortical brain areas. A multimodal use, combining EEG and various modalities of EPs is recommended since this allows a more accurate functional exploration of the brain and helps caregivers to tailor therapeutic measures according to neurological worsening trends and to anticipate the prognosis in ICU.
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Mortamet G, Kossorotoff M, Baptiste A, Boddaert N, Castelle M, Hubert P, Lesage F, Renolleau S, Oualha M. Description and Contribution of Brain Magnetic Resonance Imaging in Nontraumatic Critically Ill Children. J Child Neurol 2016; 31:1584-1590. [PMID: 27591003 DOI: 10.1177/0883073816666737] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 02/11/2016] [Revised: 07/05/2016] [Accepted: 08/02/2016] [Indexed: 11/17/2022]
Abstract
BACKGROUND The authors aimed to collect all brain magnetic resonance imaging (MRI) performed in critically ill children in the authors' medical pediatric intensive care unit over a 2-year period (2012-2013) to (1) describe the findings and (2) assess its contribution on practical patient care. METHODS This is a single-center and retrospective study. All children without traumatic brain injury who underwent a brain MRI during pediatric intensive care unit stays were included. To assess the exam's contribution, the patient's medical condition at the time of the MRI exam was blindly and separately exposed to a pediatric neurologist and a pediatric intensivist. RESULTS During the study period, 87 patients (7.5%) underwent a brain MRI. Median age was 4 months and 13 children (14.9%) died in pediatric intensive care unit. The most common final diagnosis was postanoxic encephalopathy. Brain MRI was abnormal in 68 patients (78.2%). No serious adverse event occurred during the transport. The neurologist and the intensivist considered brain MRI as indicated during pediatric intensive care unit stay in 65 (74.7%) and 68 patients (78.2%). They deemed that brain MRI had a diagnostic contribution in 76 (87.4%) and 60 (69.0%) patients, respectively. A therapeutic change consecutive to MRI findings occurred in 19 patients (21.8%) and MRI results were associated with a decision to withdraw life-sustaining treatment in 21 patients (24.1%). CONCLUSION Brain MRI is one component of neuromonitoring, and this study suggests a substantial diagnostic contribution, although its therapeutic impact appears limited to specific diagnoses.
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Affiliation(s)
- Guillaume Mortamet
- Service de Réanimation et de Surveillance continue médico-chirurgicales Pédiatriques, Hôpital Necker, Assistance Publique-des Hôpitaux de Paris, Paris, France .,Université de Montréal, Montréal, Québec, Canada
| | - Manoelle Kossorotoff
- Service de Neurologie Pédiatrique, Centre National de Référence de l'Accident Vasculaire Cérébral de l'Enfant, Hôpital Necker-Enfants malades, Assistance Publique -des Hôpitaux de Paris, Paris, France
| | - Amandine Baptiste
- Unité de Recherche Clinique/Centre d'Investigation Clinique Paris Descartes Necker, Hôpital Necker, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Nathalie Boddaert
- Service de Radiologie Pédiatrique, Hôpital Necker, Assistance Publique des Hôpitaux de Paris, Paris, France
| | - Martin Castelle
- Service de Réanimation et de Surveillance continue médico-chirurgicales Pédiatriques, Hôpital Necker, Assistance Publique-des Hôpitaux de Paris, Paris, France
| | - Philippe Hubert
- Service de Réanimation et de Surveillance continue médico-chirurgicales Pédiatriques, Hôpital Necker, Assistance Publique-des Hôpitaux de Paris, Paris, France
| | - Fabrice Lesage
- Service de Réanimation et de Surveillance continue médico-chirurgicales Pédiatriques, Hôpital Necker, Assistance Publique-des Hôpitaux de Paris, Paris, France
| | - Sylvain Renolleau
- Service de Réanimation et de Surveillance continue médico-chirurgicales Pédiatriques, Hôpital Necker, Assistance Publique-des Hôpitaux de Paris, Paris, France
| | - Mehdi Oualha
- Service de Réanimation et de Surveillance continue médico-chirurgicales Pédiatriques, Hôpital Necker, Assistance Publique-des Hôpitaux de Paris, Paris, France
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Noninvasive Vascular Methods for Detection of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage. J Clin Neurophysiol 2016; 33:260-7. [DOI: 10.1097/wnp.0000000000000271] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022] Open
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Jakobsen R, Halfeld Nielsen T, Granfeldt A, Toft P, Nordström CH. A technique for continuous bedside monitoring of global cerebral energy state. Intensive Care Med Exp 2016; 4:3. [PMID: 26791144 PMCID: PMC4720625 DOI: 10.1186/s40635-016-0077-2] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/19/2015] [Accepted: 01/11/2016] [Indexed: 12/14/2022] Open
Abstract
Background Cerebral cytoplasmatic redox state is a sensitive indicator of cerebral oxidative metabolism and is conventionally evaluated from the extracellular lactate/pyruvate (LP) ratio. In the present experimental study of global cerebral ischemia induced by hemorrhagic shock, we investigate whether the LP ratio obtained from microdialysis of cerebral venous blood may be used as a surrogate marker of global cerebral energy state. Methods Six female pigs were anesthetized and vital parameters were recorded. Microdialysis catheters were placed in the left parietal lobe, the superior sagittal sinus, and the femoral artery. Hemorrhagic shock was achieved by bleeding the animals to a mean arterial pressure (MAP) of approximately 40 mmHg and kept at a MAP of about 30–40 mmHg for 90 min. The animals were resuscitated with autologous whole blood followed by 3 h of observation. Results The LP ratio obtained from the intracerebral and intravenous catheters immediately increased during the period of hemorrhagic shock while the LP ratio in the arterial blood remained close to normal levels. At the end of the experiment, median LP ratio (interquartile range) obtained from the intracerebral, intravenous, and intra-arterial microdialysis catheters were 846 (243–1990), 309 (103–488), and 27 (21–31), respectively. There was a significant difference in the LP ratio obtained from the intravenous location and the intra-arterial location (P < 0.001). Conclusions During cerebral ischemia induced by severe hemorrhagic shock, intravascular microdialysis of the draining venous blood will exhibit changes of the LP ratio revealing the deterioration of global cerebral oxidative energy metabolism. In neurocritical care, this technique might be used to give information regarding global cerebral energy metabolism in addition to the regional information obtained from intracerebral microdialysis catheters. The technique might also be used to evaluate cerebral energy state in various critical care conditions when insertion of an intracerebral microdialysis catheter may be contraindicated, e.g., resuscitation after cardiac standstill, open-heart surgery, and multi-trauma.
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Affiliation(s)
- Rasmus Jakobsen
- Department of Anaesthesia and Intensive care, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Troels Halfeld Nielsen
- Department of Neurosurgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Asger Granfeldt
- Department of Anesthesiology, Regional Hospital of Randers, Skovlyvej 1, 8930, Randers NØ, Denmark.
| | - Palle Toft
- Department of Anaesthesia and Intensive care, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
| | - Carl-Henrik Nordström
- Department of Neurosurgery, Odense University Hospital, Sdr. Boulevard 29, 5000, Odense C, Denmark.
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Makarenko S, Griesdale DE, Gooderham P, Sekhon MS. Multimodal neuromonitoring for traumatic brain injury: A shift towards individualized therapy. J Clin Neurosci 2016; 26:8-13. [PMID: 26755455 DOI: 10.1016/j.jocn.2015.05.065] [Citation(s) in RCA: 21] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/06/2015] [Accepted: 05/30/2015] [Indexed: 01/08/2023]
Abstract
Multimodal neuromonitoring in the management of traumatic brain injury (TBI) enables clinicians to make individualized management decisions to prevent secondary ischemic brain injury. Traditionally, neuromonitoring in TBI patients has consisted of a combination of clinical examination, neuroimaging and intracranial pressure monitoring. Unfortunately, each of these modalities has its limitations and although pragmatic, this simplistic approach has failed to demonstrate improved outcomes, likely owing to an inability to consider the underlying heterogeneity of various injury patterns. As neurocritical care has evolved, so has our understanding of underlying disease pathophysiology and patient specific considerations. Recent additions to the multimodal neuromonitoring platform include measures of cerebrovascular autoregulation, brain tissue oxygenation, microdialysis and continuous electroencephalography. The implementation of neurocritical care teams to manage patients with advanced brain injury has led to improved outcomes. Herein, we present a narrative review of the recent advances in multimodal neuromonitoring and highlight the utility of dedicated neurocritical care.
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Affiliation(s)
- Serge Makarenko
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Donald E Griesdale
- Department of Anaesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada; Centre for Clinical Epidemiology and Evaluation, Vancouver Coastal Health Research Institute, University of British Columbia, Vancouver, BC, Canada; Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada
| | - Peter Gooderham
- Division of Neurosurgery, Department of Surgery, Vancouver General Hospital, University of British Columbia, Vancouver, BC, Canada
| | - Mypinder S Sekhon
- Division of Critical Care Medicine, Department of Medicine, Vancouver General Hospital, Room 2438, Jim Pattison Pavilion, 2nd Floor, 899 West 12th Avenue, University of British Columbia, Vancouver, BC V5Z 1M9, Canada.
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Abstract
Although technology over the past several decades has enabled improved neuroimaging and advanced noninvasive and invasive neuromonitoring, the role of the bedside nurse conducing ongoing neurologic examination is still a foundational element of neuromonitoring. Ongoing neurologic monitoring by the bedside nurse in the neuroscience intensive care unit is variable and guided by little evidence or data. When neurologic monitoring through clinical examination is possible, data obtained from multimodal monitoring should be interpreted in the context of the neurologic examination. The bedside nurse plays a crucial role in conducting ongoing neurologic examinations.
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Affiliation(s)
- Sarah L Livesay
- Department of Adult and Gerontology Health, Rush University College of Nursing, 600 South Paulina Street, Chicago, IL 60612, USA.
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Lazaridis C, Andrews CM. Brain tissue oxygenation, lactate-pyruvate ratio, and cerebrovascular pressure reactivity monitoring in severe traumatic brain injury: systematic review and viewpoint. Neurocrit Care 2015; 21:345-55. [PMID: 24993955 DOI: 10.1007/s12028-014-0007-7] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/25/2022]
Abstract
BACKGROUND Prevention and detection of secondary brain insults via multimodality neuromonitoring is a major goal in patients with severe traumatic brain injury (TBI). OBJECTIVE Explore the underlying pathophysiology and clinical outcome correlates as it pertains to combined monitoring of ≥2 from the following variables: partial brain tissue oxygen tension (PbtO(2)), pressure reactivity index (PRx), and lactate pyruvate ratio (LPR). METHODS Data sources included Medline, EMBASE, and evidence-based databases (Cochrane DSR, ACP Journal Club, DARE, and the Cochrane Controlled Trials Register). The PRISMA recommendations were followed. Two authors independently selected articles meeting inclusion criteria. Studies enrolled adults who required critical care and monitoring in the setting of TBI. Included studies reported on correlations between the monitored variables and/or reported on correlations of the variables with clinical outcomes. RESULTS Thirty-four reports were included (32 observational studies and 2 randomized controlled trials) with a mean sample size of 34 patients (range 6-223), and a total of 1,161 patient-observations. Overall methodological quality was moderate. Due to inter-study heterogeneity in outcomes of interest, study design, and in both number and type of covariates included in multivariable analyses, quantitative synthesis of study results was not undertaken. CONCLUSION Several literature limitations were identified including small number of subjects, lack of clinical outcome correlations, inconsistent probe location, and overall moderate quality among the included studies. These limitations preclude any firm conclusions; nevertheless we suggest that the status of cerebrovascular reactivity is not only important for cerebral perfusion pressure optimization but should also inform interpretation and interventions targeted on PbtO(2) and LPR. Assessment of reactivity can be the first step in approaching the relations among cerebral blood flow, oxygen delivery, demand, and cellular metabolism.
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Affiliation(s)
- Christos Lazaridis
- Division of Neurocritical Care, Department of Neurology, Baylor College of Medicine, 6501 Fannin Street, MS: NB 320, Houston, TX, 77030, USA,
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Recommendations for the use of multimodal monitoring in the neurointensive care unit. Curr Opin Crit Care 2015; 21:113-9. [DOI: 10.1097/mcc.0000000000000179] [Citation(s) in RCA: 41] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
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Huttner HB, Schwab S. Neurocritical care in Germany: need for guidance. Neurocrit Care 2014; 20:173-5. [PMID: 24566981 DOI: 10.1007/s12028-014-9963-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022]
Affiliation(s)
- Hagen B Huttner
- Department of Neurology, University of Erlangen-Nuremberg, Erlangen, Germany,
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Abstract
PURPOSE OF REVIEW Increased intracranial pressure (ICP) is associated with worse outcome after traumatic brain injury (TBI), but whether its management improves the outcome is unclear. In this review, we will examine the implications of the Benchmark Evidence from South American Trials: Treatment of Intracranial Pressure (BEST TRIP) trial, evidence for an influence of ICP care on outcome, and a need for greater understanding of the pathophysiology than just ICP through multimodal monitoring (MMM) to enhance the outcome. RECENT FINDINGS The primary impact of the BEST TRIP trial, a randomized clinical trial that examined two TBI management strategies, one that used an ICP monitor, is in research and should not alter clinical practice. Analyses of large databases suggest TBI care based on the Brain Trauma Foundation guidelines and management of intracranial hypertension can improve patient outcome. However, accumulating evidence demonstrates there are several mechanisms of secondary brain injury (SBI), for example, microvascular dysfunction or alterations in glucose utilization that cannot be detected using an ICP monitor. In these patients, growing clinical evidence suggests that MMM can help manage SBI and improve TBI outcome. SUMMARY ICP-based monitoring and treatment alone may not be enough to enhance TBI outcome, but ICP and cerebral perfusion pressure therapy remain important in TBI care. Although high-quality evidence for MMM is limited, it should be more widely adapted to better understand the complex pathophysiology after TBI, better target care, and identify new therapeutic opportunities.
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Abstract
PURPOSE OF REVIEW The care of critically ill brain-injured patients is complex and requires careful balancing of cerebral and systemic treatment priorities. A growing number of studies have reported improved outcomes when patients are admitted to dedicated neurocritical care units (NCCUs). The reasons for this observation have not been definitively clarified. RECENT FINDINGS When recently published articles are combined with older literature, there have been more than 40 000 patients assessed in observational studies that compare neurological and general ICUs. Although results are heterogeneous, admission to NCCUs is associated with lower mortality and a greater chance of favorable recovery. These findings are remarkable considering that there are few interventions in neurocritical care that have been demonstrated to be efficacious in randomized trials. Whether the relationship is causal is still being elucidated but potential explanations include higher patient volume and, in turn, greater clinician experience; more emphasis on and adherence to protocols to avoid secondary brain injury; practice differences related to prognostication and withdrawal of life-sustaining interventions; and differences in the use and interpretation of neuroimaging and neuromonitoring data. SUMMARY Neurocritical care is an evolving field that is associated with improvements in outcomes over the past decade. Further research is required to determine how monitoring and treatment protocols can be optimized.
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Domínguez-Berrot AM, González-Vaquero M, Díaz-Domínguez FJ, Robla-Costales J. [Multimodal neuromonitoring in traumatic brain injury: contribution of PTiO2]. Med Intensiva 2014; 38:513-21. [PMID: 24793091 DOI: 10.1016/j.medin.2014.02.005] [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: 11/26/2013] [Revised: 02/01/2014] [Accepted: 02/19/2014] [Indexed: 11/26/2022]
Abstract
The main goal of exhaustively monitoring neurocritical patients is to avoid secondary injury. In the last few years we have witnessed an increase in brain monitoring tools, beyond the checking of intracranial and brain perfusion pressures. These widely used systems offer valuable but possibly insufficient information. Awareness and correction of brain hypoxia is a useful and interesting measure, not only for diagnostic purposes but also when deciding treatment, and to predict an outcome. In this context, it would be of great interest to use all the information gathered from brain oxygenation monitoring systems in conjunction with other available multimodal monitoring devices, in order to offer individualized treatment for each patient.
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Abate MG, Citerio G. Management of subarachnoid hemorrhage. MEDECINE INTENSIVE REANIMATION 2014. [DOI: 10.1007/s13546-013-0810-8] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
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