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Systemic Hyperthermia in Traumatic Brain Injury-Relation to Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome. J Neurosurg Anesthesiol 2020; 33:329-336. [PMID: 32433101 DOI: 10.1097/ana.0000000000000695] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/17/2019] [Accepted: 04/16/2020] [Indexed: 01/09/2023]
Abstract
BACKGROUND Systemic hyperthermia is common after traumatic brain injury (TBI) and may induce secondary brain injury, although the pathophysiology is not fully understood. In this study, our aim was to determine the incidence and temporal course of hyperthermia after TBI and its relation to intracranial pressure dynamics, cerebral metabolism, and clinical outcomes. MATERIALS AND METHODS This retrospective study included 115 TBI patients. Data from systemic physiology (body temperature, blood pressure, and arterial glucose), intracranial pressure dynamics (intracranial pressure, cerebral perfusion pressure, compliance, and pressure reactivity), and cerebral microdialysis (glucose, pyruvate, lactate, glycerol, glutamate, and urea) were analyzed during the first 10 days after injury. RESULTS Overall, 6% of patients did not have hyperthermia (T>38°C) during the first 10 days after injury, whereas 20% had hyperthermia for >50% of the time. Hyperthermia increased from 21% (±27%) of monitoring time on day 1 to 36% (±29%) on days 6 to 10 after injury. In univariate analyses, higher body temperature was not associated with higher intracranial pressure nor lower cerebral perfusion pressure, but was associated with lower cerebral glucose concentration (P=0.001) and higher percentage of lactate-pyruvate ratio>25 (P=0.02) on days 6 to 10 after injury. Higher body temperature and lower arterial glucose concentration were associated with lower cerebral glucose in a multiple linear regression analysis (P=0.02 for both). There was no association between hyperthermia and worse clinical outcomes. CONCLUSION Hyperthermia was most common between days 6 and 10 following TBI, and associated with disturbances in cerebral energy metabolism but not worse clinical outcome.
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Zeiler FA, Thelin EP, Helmy A, Czosnyka M, Hutchinson PJA, Menon DK. A systematic review of cerebral microdialysis and outcomes in TBI: relationships to patient functional outcome, neurophysiologic measures, and tissue outcome. Acta Neurochir (Wien) 2017; 159:2245-2273. [PMID: 28988334 PMCID: PMC5686263 DOI: 10.1007/s00701-017-3338-2] [Citation(s) in RCA: 43] [Impact Index Per Article: 6.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/03/2017] [Accepted: 09/19/2017] [Indexed: 12/22/2022]
Abstract
OBJECTIVE To perform a systematic review on commonly measured cerebral microdialysis (CMD) analytes and their association to: (A) patient functional outcome, (B) neurophysiologic measures, and (C) tissue outcome; after moderate/severe TBI. The aim was to provide a foundation for next-generation CMD studies and build on existing pragmatic expert guidelines for CMD. METHODS We searched MEDLINE, BIOSIS, EMBASE, Global Health, Scopus, Cochrane Library (inception to October 2016). Strength of evidence was adjudicated using GRADE. RESULTS (A) Functional Outcome: 55 articles were included, assessing outcome as mortality or Glasgow Outcome Scale (GOS) at 3-6 months post-injury. Overall, there is GRADE C evidence to support an association between CMD glucose, glutamate, glycerol, lactate, and LPR to patient outcome at 3-6 months. (B) Neurophysiologic Measures: 59 articles were included. Overall, there currently exists GRADE C level of evidence supporting an association between elevated CMD measured mean LPR, glutamate and glycerol with elevated ICP and/or decreased CPP. In addition, there currently exists GRADE C evidence to support an association between elevated mean lactate:pyruvate ratio (LPR) and low PbtO2. Remaining CMD measures and physiologic outcomes displayed GRADE D or no evidence to support a relationship. (C) Tissue Outcome: four studies were included. Given the conflicting literature, the only conclusion that can be drawn is acute/subacute phase elevation of CMD measured LPR is associated with frontal lobe atrophy at 6 months. CONCLUSIONS This systematic review replicates previously documented relationships between CMD and various outcome, which have driven clinical application of the technique. Evidence assessments do not address the application of CMD for exploring pathophysiology or titrating therapy in individual patients, and do not account for the modulatory effect of therapy on outcome, triggered at different CMD thresholds in individual centers. Our findings support clinical application of CMD and refinement of existing guidelines.
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Affiliation(s)
- Frederick A. Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB R3A 1R9 Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Eric Peter Thelin
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Department of Clinical Neuroscience, Neurosurgical Research Laboratory, Karolinska University Hospital, Building R2:02, Karolinska Institutet, S-17176 Stockholm, Sweden
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
- Section of Brain Physics, Division of Neurosurgery, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Peter J. A. Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge Biomedical Campus, Cambridge, CB2 0QQ UK
| | - David K. Menon
- Department of Anesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
- Queens’ College, Cambridge, UK
- National Institute for Health Research, Southampton, UK
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A pilot microdialysis study in brain tumor patients to assess changes in intracerebral cytokine levels after craniotomy and in response to treatment with a targeted anti-cancer agent. J Neurooncol 2014; 118:169-77. [PMID: 24634191 DOI: 10.1007/s11060-014-1415-4] [Citation(s) in RCA: 20] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2013] [Accepted: 02/21/2014] [Indexed: 12/24/2022]
Abstract
Intracerebral microdialysis enables continuous measurement of changes in brain biochemistry. In this study intracerebral microdialysis was used to assess changes in cytokine levels after tumor resection and in response to treatment with temsirolimus. Brain tumor patients undergoing craniotomy participated in this non-therapeutic study. A 100 kDa molecular weight cut-off microdialysis catheter was placed in peritumoral tissue at the time of resection. Cohort 1 underwent craniotomy only. Cohort 2 received a 200 mg dose of intravenous temsirolimus 48 h after surgery. Dialysate samples were collected continuously for 96 h and analyzed for the presence of 30 cytokines. Serial blood samples were collected to measure systemic cytokine levels. Dialysate samples were obtained from six patients in cohort 1 and 4 in cohort 2. Seventeen cytokines could be recovered in dialysate samples from at least 8 of 10 patients. Concentrations of interleukins and chemokines were markedly elevated in peritumoral tissue, and most declined over time, with IL-8, IP-10, MCP-1, MIP1β, IL-6, IL-12p40/p70, MIP1α, IFN-α, G-CSF, IL-2R, and vascular endothelial growth factor significantly (p < 0.05) decreasing over 96 h following surgery. No qualitative changes in intracerebral or serum cytokine concentrations were detected after temsirolimus administration. This is the first intracerebral microdialysis study to evaluate the time course of changes in macromolecule levels in the peritumoral microenvironment after a debulking craniotomy. Initial elevations of peritumoral interleukins and chemokines most likely reflected an inflammatory response to both tumor and surgical trauma. These findings have implications for development of cellular therapies that are administered intracranially at the time of surgery.
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Czosnyka M, Citerio G. Brain compliance: the old story with a new 'et cetera'. Intensive Care Med 2012; 38:925-7. [PMID: 22527086 DOI: 10.1007/s00134-012-2572-6] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/27/2012] [Accepted: 03/27/2012] [Indexed: 11/28/2022]
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An evaluation of three measures of intracranial compliance in traumatic brain injury patients. Intensive Care Med 2012; 38:1061-8. [PMID: 22527085 DOI: 10.1007/s00134-012-2571-7] [Citation(s) in RCA: 36] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/25/2011] [Accepted: 02/20/2012] [Indexed: 10/28/2022]
Abstract
PURPOSE To compare intracranial pressure (ICP) amplitude, ICP slope, and the correlation of ICP amplitude and ICP mean (RAP index) as measures of compliance in a cohort of traumatic brain injury (TBI) patients. METHODS Mean values of the three measures were calculated in the 2-h periods before and after surgery (craniectomies and evacuations), and in the 12-h periods preceding and following thiopental treatment, and during periods of thiopental coma. The changes in the metrics were evaluated using the Wilcoxon test. The correlations of 10-day mean values for the three metrics with age, admission Glasgow Motor Score (GMS), and Extended Glasgow Outcome Score (GOSe) were evaluated. Patients under and over 60 years old were also compared using the Student t test. The correlation of ICP amplitude with systemic pulse amplitude was analyzed. RESULTS ICP amplitude was significantly correlated with GMS, and also with age for patients 35 years old and older. The correlations of ICP slope and the RAP index with GMS and with age were not significant. All three metrics indicated significant improvements in compliance following surgery and during thiopental coma. None of the metrics were significantly correlated with outcome, possibly due to confounding effects of treatment factors. The correlation of systemic pulse amplitude with ICP amplitude was low (R = 0.18), only explaining 3 % of the variance. CONCLUSIONS This study provides further validation for all three of these features of the ICP waveform as measures of compliance. ICP amplitude had the best performance in these tests.
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Nelson DW, Thornquist B, MacCallum RM, Nyström H, Holst A, Rudehill A, Wanecek M, Bellander BM, Weitzberg E. Analyses of cerebral microdialysis in patients with traumatic brain injury: relations to intracranial pressure, cerebral perfusion pressure and catheter placement. BMC Med 2011; 9:21. [PMID: 21366904 PMCID: PMC3056807 DOI: 10.1186/1741-7015-9-21] [Citation(s) in RCA: 36] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/08/2010] [Accepted: 03/02/2011] [Indexed: 11/12/2022] Open
Abstract
BACKGROUND Cerebral microdialysis (MD) is used to monitor local brain chemistry of patients with traumatic brain injury (TBI). Despite an extensive literature on cerebral MD in the clinical setting, it remains unclear how individual levels of real-time MD data are to be interpreted. Intracranial pressure (ICP) and cerebral perfusion pressure (CPP) are important continuous brain monitors in neurointensive care. They are used as surrogate monitors of cerebral blood flow and have an established relation to outcome. The purpose of this study was to investigate the relations between MD parameters and ICP and/or CPP in patients with TBI. METHODS Cerebral MD, ICP and CPP were monitored in 90 patients with TBI. Data were extensively analyzed, using over 7,350 samples of complete (hourly) MD data sets (glucose, lactate, pyruvate and glycerol) to seek representations of ICP, CPP and MD that were best correlated. MD catheter positions were located on computed tomography scans as pericontusional or nonpericontusional. MD markers were analyzed for correlations to ICP and CPP using time series regression analysis, mixed effects models and nonlinear (artificial neural networks) computer-based pattern recognition methods. RESULTS Despite much data indicating highly perturbed metabolism, MD shows weak correlations to ICP and CPP. In contrast, the autocorrelation of MD is high for all markers, even at up to 30 future hours. Consequently, subject identity alone explains 52% to 75% of MD marker variance. This indicates that the dominant metabolic processes monitored with MD are long-term, spanning days or longer. In comparison, short-term (differenced or Δ) changes of MD vs. CPP are significantly correlated in pericontusional locations, but with less than 1% explained variance. Moreover, CPP and ICP were significantly related to outcome based on Glasgow Outcome Scale scores, while no significant relations were found between outcome and MD. CONCLUSIONS The multitude of highly perturbed local chemistry seen with MD in patients with TBI predominately represents long-term metabolic patterns and is weakly correlated to ICP and CPP. This suggests that disturbances other than pressure and/or flow have a dominant influence on MD levels in patients with TBI.
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Affiliation(s)
- David W Nelson
- Neurointensive Care Unit, Karolinska University Hospital, Stockholm, Sweden.
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Blakeley J, Portnow J. Microdialysis for assessing intratumoral drug disposition in brain cancers: a tool for rational drug development. Expert Opin Drug Metab Toxicol 2010; 6:1477-91. [PMID: 20969450 DOI: 10.1517/17425255.2010.523420] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/31/2022]
Abstract
IMPORTANCE OF THE FIELD many promising targeted agents and combination therapies are being investigated for brain cancer. However, the results from recent clinical trials have been disappointing. A better understanding of the disposition of drug in the brain early in drug development would facilitate appropriate channeling of new drugs into brain cancer clinical trials. AREAS COVERED IN THIS REVIEW barriers to successful drug activity against brain cancer and issues affecting intratumoral drug concentrations are reviewed. The use of the microdialysis technique for extracellular fluid (ECF) sampling and its application to drug distribution studies in brain are reviewed using published literature from 1995 to the present. The benefits and limitations of microdialysis for performing neuorpharmacokinetic (nPK) and neuropharmacodynamic (nPD) studies are discussed. WHAT THE READER WILL GAIN the reader will gain an appreciation of the challenges involved in identifying agents likely to have efficacy in brain cancer, an understanding of the general principles of microdialysis, and the power and limitations of using this technique in early drug development for brain cancer therapies. TAKE HOME MESSAGE a major factor preventing efficacy of anti-brain cancer drugs is limited access to tumor. Intracerebral microdialysis allows sampling of drug in the brain ECF. The resulting nPK/nPD data can aid in the rational selection of drugs for investigation in brain tumor clinical trials.
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Affiliation(s)
- Jaishri Blakeley
- Johns Hopkins University, Neurosurgery and Oncology, Baltimore, MD 21231, USA.
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Eide PK, Stanisic M. Cerebral microdialysis and intracranial pressure monitoring in patients with idiopathic normal-pressure hydrocephalus: association with clinical response to extended lumbar drainage and shunt surgery. J Neurosurg 2010; 112:414-24. [PMID: 19538048 DOI: 10.3171/2009.5.jns09122] [Citation(s) in RCA: 33] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Abstract
OBJECT This study was performed in patients with idiopathic normal-pressure hydrocephalus (iNPH) to monitor cerebral metabolism with microdialysis (MD) and intracranial pressure (ICP) readings, and relate to the clinical responses to extended lumbar drainage (ELD) and shunt surgery. METHODS The baseline levels of MD metabolites and ICP were monitored overnight in 40 consecutive patients with iNPH. In a subset of 28 patients, monitoring was continued during 3 days of ELD. Thirty-one patients received a ventriculoperitoneal shunt. The clinical severity of iNPH was determined before and then 3 and 6-12 months after shunt surgery. RESULTS Altered levels of MD markers (lactate, pyruvate, lactate/pyruvate ratio, glutamate, and/or glycerol) were seen in all patients at baseline; these improved during ELD. Despite normal static ICP (mean ICP), the pulsatile ICP (the ICP wave amplitude) was increased in 24 patients (60%). Only the level of the ICP wave amplitude differentiated the ELD and/or shunt responders from nonresponders. CONCLUSIONS The MD monitoring indicated low-grade cerebral ischemia in patients with iNPH; during ELD, cerebral metabolism improved. The pulsatile ICP (the ICP wave amplitude) was the only variable differentiating the clinical responders from the nonresponders. The authors suggest that the pulsatile ICP reflects the intracranial compliance and that CSF diversion improves the biophysical milieu of the nerve cells, which subsequently may improve their biochemical milieu.
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Affiliation(s)
- Per K Eide
- Department of Neurosurgery, Division of Clinical Neuroscience, Rikshospitalet University Hospital, Oslo, Norway.
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Spiotta AM, Stiefel MF, Heuer GG, Bloom S, Maloney-Wilensky E, Yang W, Grady MS, Le Roux PD. BRAIN HYPERTHERMIA AFTER TRAUMATIC BRAIN INJURY DOES NOT REDUCE BRAIN OXYGEN. Neurosurgery 2008; 62:864-72; discussion 872. [DOI: 10.1227/01.neu.0000316900.63124.ce] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/19/2022] Open
Affiliation(s)
- Alejandro M. Spiotta
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Michael F. Stiefel
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Gregory G. Heuer
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Stephanie Bloom
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Eileen Maloney-Wilensky
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Wei Yang
- Department of Biostatistics, and Center for Clinical Epidemiology and Biostatistics, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - M. Sean Grady
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
| | - Peter D. Le Roux
- Department of Neurosurgery, University of Pennsylvania School of Medicine, Philadelphia, Pennsylvania
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Eide PK, Bentsen G, Stanisic M, Stubhaug A. Association between intracranial pulse pressure levels and brain energy metabolism in a patient with an aneurysmal subarachnoid haemorrhage. Acta Anaesthesiol Scand 2007; 51:1273-6. [PMID: 17714572 DOI: 10.1111/j.1399-6576.2007.01433.x] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/01/2022]
Abstract
This report addresses whether intracranial pulse pressure amplitudes are associated with brain energy metabolism, examined by intracerebral microdialysis. We present a 65-year-old female with an aneurysmal subarachnoid haemorrhage (SAH) from a left posterior communicating artery (PCOM) aneurysm. She underwent simultaneous intracranial pressure (ICP) monitoring and microdialysis (MD) as part of a diagnostic workout because of a lack of clinical improvement after long-term intensive care management. Over a 4-day period, a total of 128 samples of metabolites (glutamate, glycerol, lactate and pyruvate) were gathered, allowing retrospective comparisons with the levels of intracranial pulse pressure amplitudes (the mean ICP wave amplitude). During this 4-day period, mean ICP was normal (<15 mmHg), while mean ICP wave amplitude was high (>/=5 mmHg) in 47% of the recording time. There was a highly significant relationship between the levels of the mean ICP wave amplitude and the levels of glutamate, glycerol and lactate/pyruvate ratio. The levels of metabolites were increased when the mean ICP wave amplitude was >/=5 mmHg as compared with mean ICP wave amplitude levels <5 mmHg. We tentatively suggest that increased mean ICP wave amplitudes indicative of reduced intracranial compliance can be associated with brain ischaemia.
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Affiliation(s)
- P K Eide
- Department of Neurosurgery, Rikshospitalet-Radiumhospitalet University Hospital, Oslo, Norway.
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