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Srichawla BS. Future of neurocritical care: Integrating neurophysics, multimodal monitoring, and machine learning. World J Crit Care Med 2024; 13:91397. [PMID: 38855276 PMCID: PMC11155497 DOI: 10.5492/wjccm.v13.i2.91397] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/27/2023] [Revised: 01/27/2024] [Accepted: 03/06/2024] [Indexed: 06/03/2024] Open
Abstract
Multimodal monitoring (MMM) in the intensive care unit (ICU) has become increasingly sophisticated with the integration of neurophysical principles. However, the challenge remains to select and interpret the most appropriate combination of neuromonitoring modalities to optimize patient outcomes. This manuscript reviewed current neuromonitoring tools, focusing on intracranial pressure, cerebral electrical activity, metabolism, and invasive and noninvasive autoregulation monitoring. In addition, the integration of advanced machine learning and data science tools within the ICU were discussed. Invasive monitoring includes analysis of intracranial pressure waveforms, jugular venous oximetry, monitoring of brain tissue oxygenation, thermal diffusion flowmetry, electrocorticography, depth electroencephalography, and cerebral microdialysis. Noninvasive measures include transcranial Doppler, tympanic membrane displacement, near-infrared spectroscopy, optic nerve sheath diameter, positron emission tomography, and systemic hemodynamic monitoring including heart rate variability analysis. The neurophysical basis and clinical relevance of each method within the ICU setting were examined. Machine learning algorithms have shown promise by helping to analyze and interpret data in real time from continuous MMM tools, helping clinicians make more accurate and timely decisions. These algorithms can integrate diverse data streams to generate predictive models for patient outcomes and optimize treatment strategies. MMM, grounded in neurophysics, offers a more nuanced understanding of cerebral physiology and disease in the ICU. Although each modality has its strengths and limitations, its integrated use, especially in combination with machine learning algorithms, can offer invaluable information for individualized patient care.
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Affiliation(s)
- Bahadar S Srichawla
- Department of Neurology, University of Massachusetts Chan Medical School, Worcester, MA 01655, United States
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2
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Lindelauf AAMA, van Rooij JAF, Hartveld L, van der Hulst RRWJ, Weerwind PW, Schols RM. Tissue Oximetry Changes during Postoperative Dangling in Lower Extremity Free Flap Reconstruction: A Pilot Study. Life (Basel) 2023; 13:life13051158. [PMID: 37240803 DOI: 10.3390/life13051158] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/22/2022] [Revised: 04/28/2023] [Accepted: 05/09/2023] [Indexed: 05/28/2023] Open
Abstract
Background: Lower extremity free flap dangling protocols are still widely practiced, despite a paucity of evidence for their use. This pilot study investigates the use of tissue oximetry to provide further insight into the physiological effect of postoperative dangling in lower limb free flap transfer. Methods: Ten patients undergoing lower extremity free flap reconstruction were included in this study. Free flap tissue oxygen saturation (StO2) was continuously measured using non-invasive near-infrared spectroscopy. Measurements were performed on the free flap and contralateral limb during dangling from postoperative day (POD) 7 until 11, according to the local dangling protocol. Results: StO2 values measured in the free flap diminished to 70 ± 13.7% during dangling. This minimum StO2 was reached significantly later, and correspondingly the area under the curve (AUC) was significantly larger on POD 11 compared to the start of the dangling protocol on POD 7, reflecting an improving free flap microvascular reactivity. The dangling slope was equal between the free flap and contralateral leg. The reperfusion slope was significantly flatter on POD 7 compared to the other PODs (p < 0.001). Thereafter, no significant differences between PODs were observed. Patients with a history of smoking had significantly lower tissue oximetry values compared to non-smokers. Conclusions: The application of tissue oximetry during dangling provides further insight into the physiological effect (i.e., changes in microcirculatory function) of the free flap of the reconstructed lower extremity. This information could potentially be useful to either revise or disrupt the use of such dangling protocols.
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Affiliation(s)
- Anouk A M A Lindelauf
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
| | - Joep A F van Rooij
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
| | - Loes Hartveld
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
| | - René R W J van der Hulst
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
| | - Patrick W Weerwind
- Department of Cardiothoracic Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
| | - Rutger M Schols
- Department of Plastic, Reconstructive and Hand Surgery, Maastricht University Medical Center, 6202 AZ Maastricht, The Netherlands
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3
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Nontraumatic Neurosurgical Emergencies. Crit Care Nurs Q 2023; 46:2-16. [DOI: 10.1097/cnq.0000000000000434] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022]
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4
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The slope of cerebral oxyhemoglobin oscillation is associated with vascular reserve capacity in large artery steno-occlusion. Sci Rep 2021; 11:8568. [PMID: 33883666 PMCID: PMC8060335 DOI: 10.1038/s41598-021-88198-4] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2020] [Accepted: 04/05/2021] [Indexed: 11/08/2022] Open
Abstract
Inadequate cerebral perfusion is a risk factor for cerebral ischemia in patients with large artery steno-occlusion. We investigated whether prefrontal oxyhemoglobin oscillation (ΔHbO2, 0.6-2 Hz) was associated with decreased vascular reserve in patients with steno-occlusion in the large anterior circulation arteries. Thirty-six patients with steno-occlusion in the anterior circulation arteries (anterior cerebral artery, middle cerebral artery, and internal carotid artery) were included and compared to thirty-six control subjects. Patients were categorized into two groups (deteriorated vascular reserve vs. preserved vascular reserve) based on the results of Diamox single- photon emission computed tomography imaging. HbO2 data were collected using functional near-infrared spectroscopy. The slope of ΔHbO2 and the ipsilateral/contralateral slope ratio of ΔHbO2 were analyzed. Among the included patients (n = 36), 25 (69.4%) had deteriorated vascular reserve. Patients with deteriorated vascular reserve had a significantly higher average slope of ΔHbO2 on the ipsilateral side (5.01 ± 2.14) and a higher ipsilateral/contralateral ratio (1.44 ± 0.62) compared to those with preserved vascular reserve (3.17 ± 1.36, P = 0.014; 0.93 ± 0.33, P = 0.016, respectively) or the controls (3.82 ± 1.69, P = 0.019; 0.94 ± 0.29, P = 0.001). The ipsilateral/contralateral ΔHbO2 ratio could be used as a surrogate for vascular reserve in patients with severe steno-occlusion in the anterior circulation arteries.
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Felli A, Skhirtladze-Dworschak K, Opfermann P, Dworschak M. Limitations of Cerebral Oximetry in a Patient With an Intracerebral Hemorrhage and Brain Edema on Extracorporeal Membrane Oxygenation: A Case Report. A A Pract 2019; 12:390-392. [PMID: 31162164 DOI: 10.1213/xaa.0000000000000940] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/05/2022]
Abstract
Regional cerebral tissue saturation monitoring is frequently used in patients on mechanical cardiac assist devices with the intention to promptly detect critical imbalances between cerebral oxygen delivery and oxygen extraction and ultimately circumvent permanent brain injury. We report a case where an intraparenchymal bleed in the supply zone of the middle cerebral artery-followed by severe hemispherical brain edema, leading to life-threatening intracranial hypertension-escaped cerebral oximetry monitoring using near-infrared spectroscopy. Potential explanations for our observation, as well as the specific limitations of these devices, are discussed.
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Affiliation(s)
- Alessia Felli
- From the Division of Cardiothoracic and Vascular Anesthesia and Intensive Care Medicine, Department of Anesthesia, Intensive Care Medicine and Pain Medicine, General Hospital Vienna, Medical University of Vienna, Vienna, Austria
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Annus Á, Nagy A, Vécsei L, Klivényi P. 24-Hour Near-Infrared Spectroscopy Monitoring of Acute Ischaemic Stroke Patients Undergoing Thrombolysis or Thrombectomy: A Pilot Study. J Stroke Cerebrovasc Dis 2019; 28:2337-2342. [PMID: 31182266 DOI: 10.1016/j.jstrokecerebrovasdis.2019.05.026] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/23/2019] [Revised: 04/29/2019] [Accepted: 05/24/2019] [Indexed: 10/26/2022] Open
Abstract
INTRODUCTION Monitoring of acute ischaemic stroke patients during thrombolysis or thrombectomy is based mostly on frequent physical examinations, since no objective measurement of cerebrovascular haemodynamics is available in routine clinical practice. Near-infrared spectroscopy (NIRS) is a bed-side, noninvasive assessment tool that could help monitor these patients and potentially guide therapeutic interventions. Our goal in this pilot study was to investigate whether NIRS is a suitable method to monitor leptomeningeal collateral circulation via changes in cortical oxygen saturation in the first 24 hours of acute ischaemic stroke. PATIENTS AND METHODS Our study included 5 patients with acute anterior circulation infarcts. All patients received thrombolytic therapy and 1 had thrombectomy. 24-hour continuous NIRS monitoring was performed on all participants. RESULTS We aimed to give a detailed description of each NIRS recording and explain how the observed findings could correlate with changes in anterior watershed territory collateral circulation and clinical outcome. CONCLUSION Our pilot study supports the use of NIRS monitoring in acute ischaemic stroke. We believe that this technique could provide real-time information on the dynamic changes of leptomeningeal collateral circulation and help monitor the effects of thrombolysis and thrombectomy.
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Affiliation(s)
- Ádám Annus
- Department of Neurology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - András Nagy
- Department of Radiology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary
| | - László Vécsei
- Department of Neurology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary; MTA-SZTE Neuroscience Research Group, Szeged, Hungary
| | - Péter Klivényi
- Department of Neurology, Albert Szent-Györgyi Clinical Center, University of Szeged, Szeged, Hungary.
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Regional Cerebral Oxygen Saturation Changes After Decompressive Craniectomy for Malignant Cerebral Venous Thrombosis: A Prospective Cohort Study. J Neurosurg Anesthesiol 2019; 31:241-246. [DOI: 10.1097/ana.0000000000000498] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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8
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Eyeington CT, Ancona P, Osawa EA, Cutuli SL, Eastwood GM, Bellomo R. Modern technology-derived normative values for cerebral tissue oxygen saturation in adults. Anaesth Intensive Care 2019; 47:69-75. [PMID: 30864480 DOI: 10.1177/0310057x18811962] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
Modern near-infrared spectroscopy technology is increasingly adopted to measure cerebral tissue oxygen saturation. However, the normal range of cerebral tissue oxygen saturation in adults with such technology is unknown. We sought to measure cerebral tissue oxygen saturation in healthy volunteers using the novel O3 Regional Oximetry® device (Masimo Corporation, Irvine, CA, USA) and assess its relationship with key physical and haemodynamic characteristics. For ≥5 minutes, we continuously recorded cerebral tissue oxygen saturation, pulse oximetry, cardiac index and mean arterial pressure. We assessed for differences in cerebral tissue oxygen saturation between hemispheres, sex, skin type, comorbidity or smoking status, and for associations between cerebral tissue oxygen saturation and age, height, weight, SpO2and haemodynamic parameters. We recorded >32,000 observations in 98 volunteers aged 22 to 60 years, including 41 (42%) males. One-fifth had one or more co morbidities ( n=22, 22.5%), one-tenth were either current or former-smokers ( n=13, 13%), and most had a Fitzpatrick skin type of 3 or lower ( n=84, 86%). The mean combined average cerebral tissue oxygen saturation was 67.6% (95% confidence interval 66.8%-68.6%). We found statistically significant differences in cerebral tissue oxygen saturation according to hemisphere and an association between cerebral tissue oxygen saturation and mean arterial pressure and cardiac index. The combined average cerebral tissue oxygen saturation in 98 healthy volunteers was 67.6% with a narrow confidence interval and no combined average cerebral tissue oxygen saturation was below 56%. We also observed statistically significant yet quantitatively small cerebral tissue oxygen saturation differences between hemispheres, and an association between cerebral tissue oxygen saturation and mean arterial pressure and cardiac index.
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Affiliation(s)
| | - Paolo Ancona
- 1 Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Eduardo A Osawa
- 1 Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Salvatore L Cutuli
- 1 Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Glenn M Eastwood
- 1 Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia
| | - Rinaldo Bellomo
- 1 Department of Intensive Care, Austin Hospital, Melbourne, Victoria, Australia.,2 Department of Intensive Care Research, Austin Hospital, Melbourne, Australia.,3 ANZICS Research Centre, Monash University, Melbourne, Australia.,4 Department of Intensive Care, The University of Melbourne, Australia.,5 Department of Medicine, Monash University, Melbourne, Australia
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Yang M, Yang Z, Yuan T, Feng W, Wang P. A Systemic Review of Functional Near-Infrared Spectroscopy for Stroke: Current Application and Future Directions. Front Neurol 2019; 10:58. [PMID: 30804877 PMCID: PMC6371039 DOI: 10.3389/fneur.2019.00058] [Citation(s) in RCA: 70] [Impact Index Per Article: 14.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/04/2018] [Accepted: 01/16/2019] [Indexed: 02/05/2023] Open
Abstract
Background: Survivors of stroke often experience significant disability and impaired quality of life. The recovery of motor or cognitive function requires long periods. Neuroimaging could measure changes in the brain and monitor recovery process in order to offer timely treatment and assess the effects of therapy. A non-invasive neuroimaging technique near-infrared spectroscopy (NIRS) with its ambulatory, portable, low-cost nature without fixation of subjects has attracted extensive attention. Methods: We conducted a comprehensive literature review in order to review the use of NIRS in stroke or post-stroke patients in July 2018. NCBI Pubmed database, EMBASE database, Cochrane Library and ScienceDirect database were searched. Results: Overall, we reviewed 66 papers. NIRS has a wide range of application, including in monitoring upper limb, lower limb recovery, motor learning, cortical function recovery, cerebral hemodynamic changes, cerebral oxygenation, as well as in therapeutic method, clinical researches, and evaluation of the risk for stroke. Conclusions: This study provides a preliminary evidence of the application of NIRS in stroke patients as a monitoring, therapeutic, and research tool. Further studies could give more emphasize on the combination of NIRS with other techniques and its utility in the prevention of stroke.
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Affiliation(s)
- Muyue Yang
- Department of Rehabilitation Medicine, Ruijin Hospital, Shanghai, China.,School of Medicine, Shanghai Jiao Tong University, Shanghai, China
| | - Zhen Yang
- Core Facility of West China Hospital, Sichuan University, Chengdu, China
| | - Tifei Yuan
- Shanghai Mental Health Centre, Shanghai Jiao Tong University School of Medicine, Shanghai, China
| | - Wuwei Feng
- Department of Neurology, Medical University of South Carolina, Charleston, SC, United States
| | - Pu Wang
- Department of Rehabilitation Medicine, Ruijin Hospital, Shanghai, China
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Maharjan A, Peng M, Cakmak YO. Non-invasive High Frequency Median Nerve Stimulation Effectively Suppresses Olfactory Intensity Perception in Healthy Males. Front Hum Neurosci 2019; 12:533. [PMID: 30719001 PMCID: PMC6348262 DOI: 10.3389/fnhum.2018.00533] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/05/2018] [Accepted: 12/17/2018] [Indexed: 01/27/2023] Open
Abstract
Median nerve stimulation (MNS) had been performed in the existing literature to alleviate symptoms of nausea and vomiting. The observed facilitative effects are thought to be mediated by the vagal pathways, particularly the vagus nerve (VN) brainstem nuclei of the dorsal motor nucleus of vagus and nucleus tractus solitarius (DMV-NTS). Sense of smell is one of the major sensory modalities for inducing vomiting and nausea as a primary defense against potentially harmful intake of material. This study aimed to test effects of non-invasive, high and low frequency MNS on human olfactory functioning, with supplementary exploration of the orbitofrontal cortex (OFC) using near-infrared spectroscopy (NIRS). Twenty healthy, male, adults performed supra-threshold odor intensity tests (labeled magnitude scale, LMS) for four food-related odorant samples (presented in three different concentrations) before and after receiving high-, low frequency MNS and placebo (no stimulation), while cortical activities in the OFC was monitored by the NIRS. Data of the NIRS and LMS test of separate stimulation parameters were statistically analyzed using mixed-model analysis of variance (ANOVA). Only the high frequency MNS showed effects for suppressing the intensity perception of the moderate concentration of Amyl Acetate (p:0.042) and strong concentration of Isovaleric Acid (p:0.004) and 1-Octen-3-ol (p:0.006). These behavioral changes were coupled with significant changes in the NIRS recordings of the left (p:0.000) and right (p:0.003) hemispheric orbitofrontal cortices. This is the first study that applied non-invasive, high frequency MNS to suppress the supra-threshold odor ratings of specific concentrations of odors. The vagal networks are potential relays of MNS to influence OFC. Results from the current article implore further research into non-invasive, high frequency MNS in the investigation of its modulatory effects on olfactory function, given its potential to be used for ameliorating nausea and malnutrition associated with various health conditions.
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Affiliation(s)
- Ashim Maharjan
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Mei Peng
- Department of Food Science, University of Otago, Dunedin, New Zealand
| | - Yusuf O Cakmak
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand.,Brain Health Research Centre, Division of Sciences, University of Otago, Dunedin, New Zealand.,Medical Technologies Centre of Research Excellence, Auckland, New Zealand
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Giacalone G, Zanoletti M, Re R, Germinario B, Contini D, Spinelli L, Torricelli A, Roveri L. Time-domain near-infrared spectroscopy in acute ischemic stroke patients. NEUROPHOTONICS 2019; 6:015003. [PMID: 30796883 PMCID: PMC6365799 DOI: 10.1117/1.nph.6.1.015003] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/29/2018] [Accepted: 11/28/2018] [Indexed: 06/09/2023]
Abstract
Large vessel occlusion (LVO) stroke might cause different degrees of hemodynamic impairment that affects microcirculation and contributes to metabolic derangement. Time-domain near-infrared spectroscopy (TD-NIRS) estimates the oxygenation of microcirculation of cerebral outer layers. We measure hemoglobin species and tissue oxygen saturation ( StO 2 ) of anterior circulation stroke patients, classified as LVO or lacunar, and assess the differences compared with controls and according to LVO recanalization status. Fiducial markers categorize the brain region below each TD-NIRS probe as ischemic or nonstroke areas. The study includes 47 consecutive acute ischemic stroke patients and 35 controls. The ischemic area has significantly higher deoxy-hemoglobin (HbR) and total hemoglobin (HbT) compared with controls in both recanalized and nonrecanalized patients but lower StO 2 only in recanalized patients. Recanalized patients have significantly lower mean StO 2 in the ipsilateral hemisphere compared with nonrecanalized patients. This is the first study to report TD-NIRS measurements in acute ischemic stroke patients. TD-NIRS is able to detect significant differences in hemoglobin species in LVO stroke compared with controls and according to recanalization status. This preliminary data might suggest that StO 2 can serve as a surrogate functional marker of the metabolic activity of rescued brain tissue.
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Affiliation(s)
- Giacomo Giacalone
- San Raffaele Scientific Institute, Neurology Department, Via Olgettina, Milan, Italy
- San Raffaele “Vita-Salute” University, Via Olgettina, Milan, Italy
| | - Marta Zanoletti
- Politecnico di Milano, Dipartimento di Fisica, Piazza Leonardo da Vinci, Milan, Italy
| | - Rebecca Re
- Politecnico di Milano, Dipartimento di Fisica, Piazza Leonardo da Vinci, Milan, Italy
| | - Bruno Germinario
- San Raffaele Scientific Institute, Neurology Department, Via Olgettina, Milan, Italy
| | - Davide Contini
- Politecnico di Milano, Dipartimento di Fisica, Piazza Leonardo da Vinci, Milan, Italy
| | - Lorenzo Spinelli
- Istituto di Fotonica e Nanotecnologie, Consiglio Nazionale delle Ricerche, Piazza Leonardo da Vinci, Milan, Italy
| | - Alessandro Torricelli
- Politecnico di Milano, Dipartimento di Fisica, Piazza Leonardo da Vinci, Milan, Italy
- Istituto di Fotonica e Nanotecnologie, Consiglio Nazionale delle Ricerche, Piazza Leonardo da Vinci, Milan, Italy
| | - Luisa Roveri
- San Raffaele Scientific Institute, Neurology Department, Via Olgettina, Milan, Italy
- San Raffaele “Vita-Salute” University, Via Olgettina, Milan, Italy
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Maharjan A, Wang E, Peng M, Cakmak YO. Improvement of Olfactory Function With High Frequency Non-invasive Auricular Electrostimulation in Healthy Humans. Front Neurosci 2018; 12:225. [PMID: 29740266 PMCID: PMC5928377 DOI: 10.3389/fnins.2018.00225] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2017] [Accepted: 03/22/2018] [Indexed: 11/13/2022] Open
Abstract
In past literature on animal models, invasive vagal nerve stimulation using high frequencies has shown to be effective at modulating the activity of the olfactory bulb (OB). Recent advances in invasive vagal nerve stimulation in humans, despite previous findings in animal models, used low frequency stimulation and found no effect on the olfactory functioning. The present article aimed to test potential effects of non-invasive, high and low frequency vagal nerve stimulation in humans, with supplementary exploration of the orbitofrontal cortex using near-infrared spectroscopy (NIRS). Healthy, male adult participants (n = 18) performed two olfactory tests [odor threshold test (OTT) and supra-threshold test (STT)] before and after receiving high-, low frequency vagal nerve stimulation and placebo (no stimulation). Participant's olfactory functioning was monitored using NIRS, and assessed with two behavioral olfactory tests. NIRS data of separate stimulation parameters were statistically analyzed using repeated-measures ANOVA across different stages. Data from olfactory tests were analyzed using paired parametric and non-parametric statistical tests. Only high frequency, non-invasive vagal nerve stimulation was able to positively modulate the performance of the healthy participants in the STT (p = 0.021, Wilcoxon sign-ranked test), with significant differences in NIRS (p = 0.014, post-hoc with Bonferroni correction) recordings of the right hemispheric, orbitofrontal cortex. The results from the current article implore further exploration of the neurocircuitry involved under vagal nerve stimulation and the effects of non-invasive, high frequency, vagal nerve stimulation toward olfactory dysfunction which showcase in Parkinson's and Alzheimer's Diseases. Despite the sufficient effect size (moderate effect, correlation coefficient (r): 0.39 for the STT) of the current study, future research should replicate the current findings with a larger cohort.
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Affiliation(s)
- Ashim Maharjan
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand
| | - Eunice Wang
- Department of Food Science, University of Otago, Dunedin, New Zealand
| | - Mei Peng
- Department of Food Science, University of Otago, Dunedin, New Zealand
| | - Yusuf O Cakmak
- Department of Anatomy, School of Biomedical Sciences, University of Otago, Dunedin, New Zealand.,Brain Health Research Centre, Dunedin, New Zealand.,Medical Technologies Centre of Research Excellence, Auckland, New Zealand
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Al Sultan AYA, Alsubhi AMA. Anesthetic Considerations for Carotid Endarterectomy: A Postgraduate Educational Review. Anesth Essays Res 2018; 12:1-6. [PMID: 29628544 PMCID: PMC5872842 DOI: 10.4103/aer.aer_217_17] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/01/2023] Open
Abstract
Carotid endarterectomy (CEA) has shown a significant benefit in preventing ipsilateral stroke when it is compared to conservative management. Surgical morbidity and mortality must be kept to a minimum to achieve this benefit. Neurological status of the CEA patients can be monitored easily during regional anesthesia depending on the awake testing (neurocognitive assessment) method of the CEA patients. In addition, specific parameters can help us to monitor and to predict the neurological status of the CEA patients during the procedures such as regional cerebral oxygen saturation (rSO2) and middle cerebral artery velocity (MCAv) changes. We conducted a computerized literature search involving humans, published in English until December 2017, and indexed through Medical Databases; MEDLINE/PubMed, EMBASE, and Web of Science. We reviewed articles performed for prospective and other types of studies related to CEA procedures and techniques which can predict patient's status during the procedure. Searching relevant articles and discussing the results to allow meaningful rate comparison, and to conclude a result view which benefits the CEA patients and the medical staff during the CEA procedures. In total, studies observed cerebral rSO2 and MCAv have significant value during CEA procedures. Patients with neurological symptoms during the procedures showed changes of cerebral rSO2 and MCAv more than the patients without neurological symptoms. Mentioned parameters (cerebral rSO2 and MCAv) showed significant increasing right after the procedure. Mostly, CEA surgeries under local anesthesia were observed, for monitoring patients' consciousness status and comparing it to patients who undergo general anesthesia, to view the reliability of these techniques during CEA procedures, and to predict and avoid intraoperative neurological symptoms.
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Shah S, Kimberly WT. Today's Approach to Treating Brain Swelling in the Neuro Intensive Care Unit. Semin Neurol 2016; 36:502-507. [PMID: 27907954 DOI: 10.1055/s-0036-1592109] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/27/2022]
Abstract
Brain swelling is an urgent clinical problem that frequently accompanies ischemic stroke, brain hemorrhage, and traumatic brain injury; it increases morbidity and mortality associated with them. It occurs due to failure of membrane transporters and leakage of the blood-brain barrier (BBB), resulting in combination of cytotoxic, ionic, and vasogenic edema. Currently, decompressive craniectomy and osmotherapy are the mainstays of management, but these therapies do not halt the underlying molecular cascade leading to brain swelling. Recent advances in the molecular underpinnings of cerebral edema have opened up possibilities of newer targeted therapeutic options. Here the authors outline the current approach for rapid diagnosis and intervention to reduce mortality and morbidity associated with brain swelling.
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Affiliation(s)
- Shreyansh Shah
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
| | - W Taylor Kimberly
- Division of Neurocritical Care and Emergency Neurology, Department of Neurology, Massachusetts General Hospital, Boston, Massachusetts
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Abstract
A mismatch between cerebral oxygen supply and demand can lead to cerebral hypoxia/ischemia and deleterious outcomes. Cerebral oxygenation monitoring is an important aspect of multimodality neuromonitoring. It is increasingly deployed whenever intracranial pressure monitoring is indicated. Although there is a large body of evidence demonstrating an association between cerebral hypoxia/ischemia and poor outcomes, it remains to be determined whether restoring cerebral oxygenation leads to improved outcomes. Randomized prospective studies are required to address uncertainties about cerebral oxygenation monitoring and management. This article describes the different methods of monitoring cerebral oxygenation, their indications, evidence base, limitations, and future perspectives.
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Affiliation(s)
- Matthew A Kirkman
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK
| | - Martin Smith
- Neurocritical Care Unit, The National Hospital for Neurology and Neurosurgery, University College London Hospitals, Queen Square, London WC1N 3BG, UK.
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Moreau F, Yang R, Nambiar V, Demchuk AM, Dunn JF. Near-infrared measurements of brain oxygenation in stroke. NEUROPHOTONICS 2016; 3:031403. [PMID: 26958577 PMCID: PMC4750462 DOI: 10.1117/1.nph.3.3.031403] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Received: 05/01/2015] [Accepted: 01/13/2016] [Indexed: 05/17/2023]
Abstract
We investigated the feasibility of using frequency-domain near-infrared spectroscopy (fdNIRS) to study brain oxygenation in the first few hours of stroke onset. The OxiplexTS(®) fdNIRS system was used in this study. Using a standard probing protocol based on surface landmarks, we measured brain tHb and [Formula: see text] in healthy volunteers, cadavers, and acute stroke patients within 9 h of stroke onset and 3 days later. We obtained measurements from 11 controls, 5 cadavers, and 5 acute stroke patients. [Formula: see text] values were significantly lower in cadavers compared to the controls and stroke patients. Each stroke patient had at least one area with reduced [Formula: see text] on the stroke side compared to the contralateral side. The evolution of tHb and [Formula: see text] at 3 days differed depending on whether a large infarct occurred. This study shows the proof of principle that quantified measurements of brain oxygenation using NIRS could be used in the hectic environment of acute stroke management. It also highlights the current technical limitations and future challenges in the development of this unique bedside monitoring tool for stroke.
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Affiliation(s)
- François Moreau
- Université de Sherbrooke, Department of Medicine, CHUS-Hôpital Fleurimont 3001, 12e Avenue Nord, bureau 6501, Québec, Sherbrooke J1H 5N4, Canada
- Calgary Stroke Program, Department of Clinical Neurosciences, Foothills Medical Centre, 12th Floor, 1403-29th Street NW Calgary, Alberta T2N 2T9, Canada
- Address all correspondence to: François Moreau, E-mail:
| | - Runze Yang
- University of Calgary, Department of Radiology, Foothills Medical Centre, Room 812, North Tower, 1403-29th Street NW Calgary, Alberta T2N 2T9, Canada
- University of Calgary, Hotchkiss Brain Institute, Health Research Innovation Centre, Room 1A10, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Vivek Nambiar
- Calgary Stroke Program, Department of Clinical Neurosciences, Foothills Medical Centre, 12th Floor, 1403-29th Street NW Calgary, Alberta T2N 2T9, Canada
- Amrita Institute Medical Sciences, Department of Neurology, Center of Neurosciences, Ponekkara, Kochi 682041, India
| | - Andrew M. Demchuk
- Calgary Stroke Program, Department of Clinical Neurosciences, Foothills Medical Centre, 12th Floor, 1403-29th Street NW Calgary, Alberta T2N 2T9, Canada
- University of Calgary, Hotchkiss Brain Institute, Health Research Innovation Centre, Room 1A10, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
| | - Jeff F. Dunn
- University of Calgary, Department of Radiology, Foothills Medical Centre, Room 812, North Tower, 1403-29th Street NW Calgary, Alberta T2N 2T9, Canada
- University of Calgary, Hotchkiss Brain Institute, Health Research Innovation Centre, Room 1A10, 3330 Hospital Drive NW, Calgary, Alberta T2N 4N1, Canada
- University of Calgary, Experimental Imaging Center, TRW building, Basement level P2, Foothills Medical Centre, 1403-29th Street NW Calgary, Alberta T2N 2T9, Canada
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Abstract
Maintenance of adequate oxygenation is a mainstay of intensive care, however, recommendations on the safety, accuracy, and the potential clinical utility of invasive and non-invasive tools to monitor brain and systemic oxygenation in neurocritical care are lacking. A literature search was conducted for English language articles describing bedside brain and systemic oxygen monitoring in neurocritical care patients from 1980 to August 2013. Imaging techniques e.g., PET are not considered. A total of 281 studies were included, the majority described patients with traumatic brain injury (TBI). All tools for oxygen monitoring are safe. Parenchymal brain oxygen (PbtO2) monitoring is accurate to detect brain hypoxia, and it is recommended to titrate individual targets of cerebral perfusion pressure (CPP), ventilator parameters (PaCO2, PaO2), and transfusion, and to manage intracranial hypertension, in combination with ICP monitoring. SjvO2 is less accurate than PbtO2. Given limited data, NIRS is not recommended at present for adult patients who require neurocritical care. Systemic monitoring of oxygen (PaO2, SaO2, SpO2) and CO2 (PaCO2, end-tidal CO2) is recommended in patients who require neurocritical care.
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Hametner C, Stanarcevic P, Stampfl S, Rohde S, Veltkamp R, Bösel J. Noninvasive cerebral oximetry during endovascular therapy for acute ischemic stroke: an observational study. J Cereb Blood Flow Metab 2015; 35:1722-8. [PMID: 26243709 PMCID: PMC4635248 DOI: 10.1038/jcbfm.2015.181] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.1] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/21/2015] [Revised: 06/18/2015] [Accepted: 06/22/2015] [Indexed: 01/20/2023]
Abstract
Implementing endovascular stroke care often impedes neurologic assessment in patients who need sedation or general anesthesia. Cerebral near-infrared spectroscopy (NIRS) may help physicians monitor cerebral tissue viability, but data in hyperacute stroke patients receiving endovascular treatment are sparse. In this observational study, the NIRS index regional oxygen saturation (rSO2) was measured noninvasively before, during, and after endovascular therapy via bilateral forehead NIRS optodes. During the study period, 63 patients were monitored with NIRS; 43 qualified for analysis. Before recanalization, 10 distinct rSO2 decreases occurred in 11 patients with respect to time to intubation. During recanalization, two kinds of unilateral rSO2 changes occurred in the affected hemisphere: small peaks throughout the treatment (n=14, 32.6%) and sustained increases immediately after recanalization (n=2, 4.7%). Lower area under the curve 10% below baseline was associated with better reperfusion status (thrombolysis in cerebral infarction ≥ 2b, P=0.009). At the end of the intervention, lower interhemispheric rSO2 difference predicted death within 90 days (P=0.037). After the intervention, higher rSO2 variability predicted poor outcome (modified Rankin scale > 3, P=0.032). Our findings suggest that bi-channel rSO2-NIRS has potential for guiding neuroanesthesia and predicting outcome. To better monitor local revascularization, an improved stroke-specific set-up in future studies is necessary.
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Affiliation(s)
| | - Predrag Stanarcevic
- Neurology Clinic, Clinical Centre of Serbia, University of Belgrade, Belgrade, Serbia
| | - Sibylle Stampfl
- Department of Neuroradiology, University of Heidelberg, Heidelberg, Germany
| | - Stefan Rohde
- Department of Radiology and Neuroradiology, Klinikum Dortmund, Dortmund, Germany
| | - Roland Veltkamp
- Department of Neurology/Stroke, Imperial College, London, UK
| | - Julian Bösel
- Department of Neurology, University of Heidelberg, Heidelberg, Germany
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Nouveaux outils de neuromonitorage. MEDECINE INTENSIVE REANIMATION 2015. [DOI: 10.1007/s13546-015-1099-6] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/23/2022]
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20
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Usefulness of near-infrared spectroscopy in thrombectomy monitoring. J Clin Monit Comput 2014; 29:585-9. [DOI: 10.1007/s10877-014-9636-9] [Citation(s) in RCA: 9] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/24/2014] [Accepted: 10/24/2014] [Indexed: 10/24/2022]
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21
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Abstract
Neuroimaging has expanded beyond its traditional diagnostic role and become a critical tool in the evaluation and management of stroke. The objectives of imaging include prompt accurate diagnosis, treatment triage, prognosis prediction, and secondary preventative precautions. While capitalizing on the latest treatment options and expanding upon the "time is brain" doctrine, the ultimate goal of imaging is to maximize the number of treated patients and improve the outcome of one the most costly and morbid disease. A broad overview of comprehensive multimodal stroke imaging is presented here to affirm its utilization.
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Affiliation(s)
- Elizabeth Tong
- Neuroradiology Division, Department of Radiology, University of Virginia, Charlottesville, Virginia
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22
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Delgado AP, Deutschmann H, Schwarz G. [Transcranial cerebral oxymetry in interventional neuroradiology. Sources of error in interpretation of measurement data]. Anaesthesist 2014; 62:919-23. [PMID: 24114381 DOI: 10.1007/s00101-013-2245-z] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
Abstract
Transcranial cerebral oximetry is a non-invasive method to support the estimation of the balance in cerebral oxygen metabolism status during interventional neuroradiological procedures. The simple data acquisition can lead to errors by oversimplification in interpretation of the displayed data. To avoid fatal mistakes of the acquired data the complex interactions of the examined substrate with physiological and pathophysiological interactions have to be critically judged as well as the procedural approach and methodological limitations.
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Affiliation(s)
- A P Delgado
- Klinische Abteilung für Neuro-und Gesichtschirurgische, Anästhesiologie und Intensivmedizin, Universitätsklinik für Anästhesiologie und Intensivmedizin, Medizinischen Universität Graz, Auenbruggerplatz 29/I, 8036, Graz, Österreich,
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Damian M, Czosnyka M. Near infrared spectroscopy monitoring—Opening a window on the first 24h after cardiac arrest? Resuscitation 2014; 85:452-3. [DOI: 10.1016/j.resuscitation.2014.01.022] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/28/2014] [Accepted: 01/28/2014] [Indexed: 12/01/2022]
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Wijdicks EFM, Sheth KN, Carter BS, Greer DM, Kasner SE, Kimberly WT, Schwab S, Smith EE, Tamargo RJ, Wintermark M. Recommendations for the management of cerebral and cerebellar infarction with swelling: a statement for healthcare professionals from the American Heart Association/American Stroke Association. Stroke 2014; 45:1222-38. [PMID: 24481970 DOI: 10.1161/01.str.0000441965.15164.d6] [Citation(s) in RCA: 306] [Impact Index Per Article: 30.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
BACKGROUND AND PURPOSE There are uncertainties surrounding the optimal management of patients with brain swelling after an ischemic stroke. Guidelines are needed on how to manage this major complication, how to provide the best comprehensive neurological and medical care, and how to best inform families facing complex decisions on surgical intervention in deteriorating patients. This scientific statement addresses the early approach to the patient with a swollen ischemic stroke in a cerebral or cerebellar hemisphere. METHODS The writing group used systematic literature reviews, references to published clinical and epidemiology studies, morbidity and mortality reports, clinical and public health guidelines, authoritative statements, personal files, and expert opinion to summarize existing evidence and to indicate gaps in current knowledge. The panel reviewed the most relevant articles on adults through computerized searches of the medical literature using MEDLINE, EMBASE, and Web of Science through March 2013. The evidence is organized within the context of the American Heart Association framework and is classified according to the joint American Heart Association/American College of Cardiology Foundation and supplementary American Heart Association Stroke Council methods of classifying the level of certainty and the class and level of evidence. The document underwent extensive American Heart Association internal peer review. RESULTS Clinical criteria are available for hemispheric (involving the entire middle cerebral artery territory or more) and cerebellar (involving the posterior inferior cerebellar artery or superior cerebellar artery) swelling caused by ischemic infarction. Clinical signs that signify deterioration in swollen supratentorial hemispheric ischemic stroke include new or further impairment of consciousness, cerebral ptosis, and changes in pupillary size. In swollen cerebellar infarction, a decrease in level of consciousness occurs as a result of brainstem compression and therefore may include early loss of corneal reflexes and the development of miosis. Standardized definitions should be established to facilitate multicenter and population-based studies of incidence, prevalence, risk factors, and outcomes. Identification of patients at high risk for brain swelling should include clinical and neuroimaging data. If a full resuscitative status is warranted in a patient with a large territorial stroke, admission to a unit with neurological monitoring capabilities is needed. These patients are best admitted to intensive care or stroke units attended by skilled and experienced physicians such as neurointensivists or vascular neurologists. Complex medical care includes airway management and mechanical ventilation, blood pressure control, fluid management, and glucose and temperature control. In swollen supratentorial hemispheric ischemic stroke, routine intracranial pressure monitoring or cerebrospinal fluid diversion is not indicated, but decompressive craniectomy with dural expansion should be considered in patients who continue to deteriorate neurologically. There is uncertainty about the efficacy of decompressive craniectomy in patients ≥60 years of age. In swollen cerebellar stroke, suboccipital craniectomy with dural expansion should be performed in patients who deteriorate neurologically. Ventriculostomy to relieve obstructive hydrocephalus after a cerebellar infarct should be accompanied by decompressive suboccipital craniectomy to avoid deterioration from upward cerebellar displacement. In swollen hemispheric supratentorial infarcts, outcome can be satisfactory, but one should anticipate that one third of patients will be severely disabled and fully dependent on care even after decompressive craniectomy. Surgery after a cerebellar infarct leads to acceptable functional outcome in most patients. CONCLUSIONS Swollen cerebral and cerebellar infarcts are critical conditions that warrant immediate, specialized neurointensive care and often neurosurgical intervention. Decompressive craniectomy is a necessary option in many patients. Selected patients may benefit greatly from such an approach, and although disabled, they may be functionally independent.
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Nielsen TH, Ståhl N, Schalén W, Reinstrup P, Toft P, Nordström CH. Recirculation usually precedes malignant edema in middle cerebral artery infarcts. Acta Neurol Scand 2012; 126:404-10. [PMID: 22494199 DOI: 10.1111/j.1600-0404.2012.01664.x] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 03/08/2012] [Indexed: 11/30/2022]
Abstract
OBJECTIVES In patients with large middle cerebral artery (MCA) infarcts, maximum brain swelling leading to cerebral herniation and death usually occurs 2-5 days after onset of stroke. The study aimed at exploring the pattern of compounds related to cerebral energy metabolism in infarcted brain tissue. METHODS Forty-four patients with malignant MCA infarcts were included after decision to perform decompressive hemicraniectomy (DHC). Cerebral energy metabolism was in all patients monitored bedside by 1-3 microdialysis catheters inserted into the infarcted hemisphere during DHC. In 29 of the patients, one microdialysis catheter was also placed in the non-infarcted hemisphere. MCA blood-flow velocity was monitored bilaterally by transcranial Doppler ultrasound. RESULTS The interstitial glucose levels were in both sides within normal limits throughout the monitoring period. Mean lactate/pyruvate (LP) ratio was very high in infarcted tissue immediately after DHC. The ratio slowly decreased but did not reach normal level during the study period. In the infarcted hemisphere, MCA blood-flow velocities increased from approximately 42 cm/s 1 day prior to DHC (nine of nine patients) to approximately 60 cm/s at day 4. CONCLUSIONS Normal interstitial glucose level in the infarcted hemisphere in combination with substantial MCA blood-flow velocities bilaterally even before DHC was performed indicates that malignant brain swelling usually commences when the embolus/thrombosis has been largely resolved and recirculation of the infarcted area has started. The protracted increase of the LP ratio in infarcted tissue might indicate mitochondrial dysfunction.
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Affiliation(s)
- T. H. Nielsen
- Department of Neurosurgery; Odense University Hospital; Odense; Denmark
| | - N. Ståhl
- Department of Neurosurgery; Lund University Hospital; Lund; Sweden
| | - W. Schalén
- Department of Neurosurgery; Lund University Hospital; Lund; Sweden
| | - P. Reinstrup
- Department of Neurosurgery; Lund University Hospital; Lund; Sweden
| | - P Toft
- Department of Anesthesiology; Odense University Hospital; Odense; Denmark
| | - C. H. Nordström
- Department of Neurosurgery; Odense University Hospital; Odense; Denmark
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26
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Schytz HW, Guo S, Jensen LT, Kamar M, Nini A, Gress DR, Ashina M. A new technology for detecting cerebral blood flow: a comparative study of ultrasound tagged NIRS and 133Xe-SPECT. Neurocrit Care 2012; 17:139-45. [PMID: 22610823 DOI: 10.1007/s12028-012-9720-2] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Abstract
There is a need for real-time non-invasive, continuous monitoring of cerebral blood flow (CBF) during surgery, in intensive care units and clinical research. We investigated a new non-invasive hybrid technology employing ultrasound tagged near infrared spectroscopy (UT-NIRS) that may estimate changes in CBF using a cerebral blood flow index (CFI). Changes over time for UT-NIRS CFI and 133Xenon single photon emission computer tomography (133Xe-SPECT) CBF data were assessed in 10 healthy volunteers after an intravenous bolus of acetazolamide. UT-NIRS CFI was measured continuously and SPECT CBF was measured at baseline, 15 and 60 min after acetazolamide. We found significant changes over time in CFI by UT-NIRS and CBF by SPECT after acetazolamide (P ≤ 0.001). Post hoc tests showed a significant increase in CFI (P = 0.011) and SPECT CBF (P < 0.001) at 15 min after acetazolamide injection. There was a significant correlation between CFI and SPECT CBF values (r = 0.67 and P ≤ 0.033) at 15 min, but not at 60 min (P ≥ 0.777). UT-NIRS detected an increase in CFI following an acetazolamide bolus, which correlated with CBF measured with 133Xe-SPECT. This study demonstrates that UT-NIRS technology may be a promising new technique for non-invasive and real-time bedside CBF monitoring.
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Affiliation(s)
- Henrik W Schytz
- Danish Headache Center and Department of Neurology, Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, 2600, Glostrup, Denmark.
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Yannopoulos F, Mäkelä T, Arvola O, Haapanen H, Anttila V, Kiviluoma K, Juvonen T. Remote ischemic precondition preserves cerebral oxygen tension during hypothermic circulatory arrest. SCAND CARDIOVASC J 2012; 46:245-50. [DOI: 10.3109/14017431.2012.661874] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/13/2022]
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Aries MJH, Coumou AD, Elting JWJ, van der Harst JJ, Kremer BPH, Vroomen PCAJ. Near infrared spectroscopy for the detection of desaturations in vulnerable ischemic brain tissue: a pilot study at the stroke unit bedside. Stroke 2011; 43:1134-6. [PMID: 22198984 DOI: 10.1161/strokeaha.111.636894] [Citation(s) in RCA: 39] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/16/2022]
Abstract
BACKGROUND AND PURPOSE There is uncertainty whether bilateral near infrared spectroscopy (NIRS) can be used for monitoring of patients with acute stroke. METHODS The NIRS responsiveness to systemic and stroke-related changes was studied overnight by assessing the effects of brief peripheral arterial oxygenation and mean arterial pressure alterations in the affected versus nonaffected hemisphere in 9 patients with acute stroke. RESULTS Significantly more NIRS drops were registered in the affected compared with the nonaffected hemisphere (477 drops versus 184, P<0.001). In the affected hemispheres, nearly all peripheral arterial oxygenation drops (n=128; 96%) were detected by NIRS; in the nonaffected hemispheres only 23% (n=30; P=0.17). Only a few mean arterial pressure drops were followed by a significant NIRS drop. This was however significantly different between both hemispheres (32% versus 13%, P=0.01). CONCLUSIONS This pilot study found good responsiveness of NIRS signal to systemic and stroke-related changes at the bedside but requires confirmation in a larger sample.
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Affiliation(s)
- Marcel J H Aries
- University Medical Centre Groningen, Department of Neurology, The Netherlands, Hanzeplein 1, 9700 RB Groningen.
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Obrig H, Steinbrink J. Non-invasive optical imaging of stroke. PHILOSOPHICAL TRANSACTIONS. SERIES A, MATHEMATICAL, PHYSICAL, AND ENGINEERING SCIENCES 2011; 369:4470-94. [PMID: 22006902 DOI: 10.1098/rsta.2011.0252] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
The acute onset of a neurological deficit is the key clinical feature of stroke. In most cases, however, pathophysiological changes in the cerebral vasculature precede the event, often by many years. Persisting neurological deficits may also require long-term rehabilitation. Hence, stroke may be considered a chronic disease, and diagnostic and therapeutic efforts must include identification of specific risk factors, and the monitoring of and interventions in the acute and subacute stages, and should aim at a pathophysiologically based approach to optimize the rehabilitative effort. Non-invasive optical techniques have been experimentally used in all three stages of the disease and may complement the established diagnostic and monitoring tools. Here, we provide an overview of studies using the methodology in the context of stroke, and we sketch perspectives of how they may be integrated into the assessment of the highly dynamic pathophysiological processes during the acute and subacute stages of the disease and also during rehabilitation and (secondary) prevention of stroke.
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Affiliation(s)
- Hellmuth Obrig
- Department of Cognitive Neurology, University Hospital Leipzig, Liebigstraße 16, 04103 Leipzig, Germany.
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Irazuzta J, Sullivan KJ. Hyperacute therapies for childhood stroke: a case report and review of the literature. Neurol Res Int 2010; 2010:497326. [PMID: 21152213 PMCID: PMC2989694 DOI: 10.1155/2010/497326] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/03/2010] [Revised: 04/22/2010] [Accepted: 06/30/2010] [Indexed: 11/17/2022] Open
Abstract
Objective. The optimal management of pediatric patients with arterial ischemic stroke (AIS) is not known. Despite this, goal-oriented, time-sensitive therapies geared to rapid reestablishment of arterial blood flow are occasionally applied with beneficial effects. The inconsistent approach to AIS is in part due to a lack of knowledge and preparedness. Methods. Case report of a 12-year-old male with right middle cerebral artery (MCA) occlusion resulting in dense left hemiplegia and mutism and review of the literature. Intervention(s). Mechanical thrombectomy, intra-arterial administration of rt-PA, vasodilators, and platelet inhibitors, and systemic anticoagulation and subsequent critical care support. Results. Restoration of right MCA blood flow and complete resolution of neurologic deficits. Conclusion. We report the gratifying outcome of treatment of a case of AIS in a pediatric patient treated with hyperacute therapies geared to arterial recanalization and subsequent neurologic critical care and review the pertinent literature. Guidelines for the emergency room management of pediatric AIS from prospective, randomized trials are needed.
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Affiliation(s)
- Jose Irazuzta
- Division of Pediatric Critical Care Medicine, University of Florida Health Science Center at Jacksonville and The Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, USA
| | - Kevin J. Sullivan
- Division of Pediatric Critical Care Medicine, University of Florida Health Science Center at Jacksonville and The Wolfson Children's Hospital, 800 Prudential Drive, Jacksonville, FL 32207, USA
- Department of Anesthesia, Mayo Clinic Rochester, Rochester, MN 55905, USA
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Durduran T, Choe R, Baker WB, Yodh AG. Diffuse Optics for Tissue Monitoring and Tomography. REPORTS ON PROGRESS IN PHYSICS. PHYSICAL SOCIETY (GREAT BRITAIN) 2010; 73:076701. [PMID: 26120204 PMCID: PMC4482362 DOI: 10.1088/0034-4885/73/7/076701] [Citation(s) in RCA: 555] [Impact Index Per Article: 39.6] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
This review describes the diffusion model for light transport in tissues and the medical applications of diffuse light. Diffuse optics is particularly useful for measurement of tissue hemodynamics, wherein quantitative assessment of oxy- and deoxy-hemoglobin concentrations and blood flow are desired. The theoretical basis for near-infrared or diffuse optical spectroscopy (NIRS or DOS, respectively) is developed, and the basic elements of diffuse optical tomography (DOT) are outlined. We also discuss diffuse correlation spectroscopy (DCS), a technique whereby temporal correlation functions of diffusing light are transported through tissue and are used to measure blood flow. Essential instrumentation is described, and representative brain and breast functional imaging and monitoring results illustrate the workings of these new tissue diagnostics.
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Affiliation(s)
- T Durduran
- ICFO- Institut de Ciències Fotòniques, Mediterranean Technology Park, 08860 Castelldefels (Barcelona), Spain
| | - R Choe
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - W B Baker
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA
| | - A G Yodh
- Department of Physics and Astronomy, University of Pennsylvania, Philadelphia, PA 19104, USA
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Muehlschlegel S, Selb J, Patel M, Diamond SG, Franceschini MA, Sorensen AG, Boas DA, Schwamm LH. Feasibility of NIRS in the neurointensive care unit: a pilot study in stroke using physiological oscillations. Neurocrit Care 2009; 11:288-95. [PMID: 19649749 DOI: 10.1007/s12028-009-9254-4] [Citation(s) in RCA: 39] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2009] [Accepted: 07/21/2009] [Indexed: 11/28/2022]
Abstract
INTRODUCTION Near-infrared spectroscopy (NIRS) is a non-invasive, real-time bedside modality sensitive to changes in cerebral perfusion and oxygenation and is highly sensitive to physiological oscillations at different frequencies. However, the clinical feasibility of NIRS remains limited, partly due to concerns regarding NIRS signal quantification, which relies on mostly arbitrary assumptions on hemoglobin concentrations and tissue layers. In this pilot study comparing stroke patients to healthy controls, we explored the utility of the interhemispheric correlation coefficient (IHCC) during physiological oscillations in detecting asymmetry in hemispheric microvascular hemodynamics. METHODS Using bi-hemispheric continuous-wave NIRS, 12 patients with hemispheric strokes and 9 controls were measured prospectively. NIRS signal was band-pass filtered to isolate cardiac (0.7-3 Hz) and respiratory (0.15-0.7 Hz) oscillations. IHCCs were calculated in both oscillation frequency bands. Using Fisher's Z-transform for non-Gaussian distributions, the IHCC during cardiac and respiratory oscillations were compared between both groups. RESULTS Nine patients and nine controls had data of sufficient quality to be included in the analysis. The IHCCs during cardiac and respiratory oscillations were significantly different between patients versus controls (cardiac 0.79 +/- 0.18 vs. 0.94 +/- 0.07, P = 0.025; respiratory 0.24 +/- 0.28 vs. 0.59 +/- 0.3; P = 0.016). CONCLUSIONS Computing the IHCC during physiological cardiac and respiratory oscillations may be a new NIRS analysis technique to quantify asymmetric microvascular hemodynamics in stroke patients in the neurocritical care unit. It allows each subject to serve as their own control obviating the need for arbitrary assumptions on absolute hemoglobin concentration. Future clinical applications may include rapid identification of patients with ischemic brain injury in the pre-hospital setting. This promising new analysis technique warrants further validation.
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Affiliation(s)
- Susanne Muehlschlegel
- Neurocritical Care Service, Department of Neurology, UMASS Memorial Medical Center, University of Massachusetts Medical School, 55 Lake Ave North, University Campus, S-5, Worcester, MA 01655, USA.
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Schytz HW, Wienecke T, Jensen LT, Selb J, Boas DA, Ashina M. Changes in cerebral blood flow after acetazolamide: an experimental study comparing near-infrared spectroscopy and SPECT. Eur J Neurol 2009; 16:461-7. [PMID: 19236469 DOI: 10.1111/j.1468-1331.2008.02398.x] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/28/2022]
Abstract
BACKGROUND AND PURPOSE It is important to find a reliable and bedside method, which can estimate the cerebral blood flow (CBF) of patients in clinical settings. Estimation of CBF by calculating a blood flow index (BFI) using continuous wave near-infrared spectroscopy (CW-NIRS) and indocyanine green (ICG) as an i.v. tracer has been proposed to be a feasible and promising method. To validate if the BFI method can detect relative changes in CBF we compared data with the established method (133)Xenon single photon emission computer tomography ((133)Xe-SPECT). METHODS Ten healthy subjects were investigated before and after a bolus of acetazolamide. NIRS data were obtained using a multi source detector separation configuration in order to assess a corrected BFI (BFI(corr)) value, which attempts to eliminate contamination of skin blood flow. RESULTS Data obtained showed no significant correlation between CBF changes measured by (133)Xe-SPECT and BFI(corr) (0.133, P = 0.732). After acetazolamide, a 49% increase in CBF was detected using the (133)Xe-SPECT method, whereas no changes in any ICG variables were observed after acetazolamide. CONCLUSION The study shows that it is not possible to obtain reliable BFI data, which reflect changes in CBF after acetazolamide infusion, using the CW-NIRS and ICG method.
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Affiliation(s)
- H W Schytz
- Danish Headache Center and Department of Neurology Glostrup Hospital, Faculty of Health Sciences, University of Copenhagen, Glostrup, Denmark.
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Durduran T, Zhou C, Edlow BL, Yu G, Choe R, Kim MN, Cucchiara BL, Putt ME, Shah Q, Kasner SE, Greenberg JH, Yodh AG, Detre JA. Transcranial optical monitoring of cerebrovascular hemodynamics in acute stroke patients. OPTICS EXPRESS 2009; 17:3884-902. [PMID: 19259230 PMCID: PMC2724658 DOI: 10.1364/oe.17.003884] [Citation(s) in RCA: 76] [Impact Index Per Article: 5.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 05/18/2023]
Abstract
"Diffuse correlation spectroscopy" (DCS) is a technology for non-invasive transcranial measurement of cerebral blood flow (CBF) that can be hybridized with "near-infrared spectroscopy" (NIRS). Taken together these methods hold potential for monitoring hemodynamics in stroke patients. We explore the utility of DCS and NIRS to measure effects of head-of-bed (HOB) positioning at 30 degrees , 15 degrees , 0 degrees , -5 degrees and 0 degrees angles in patients with acute ischemic stroke affecting frontal cortex and in controls. HOB positioning significantly altered CBF, oxy-hemoglobin (HbO(2)) and total-hemoglobin (THC) concentrations. Moreover, the presence of an ipsilateral infarct was a significant effect for all parameters. Results are consistent with the notion of impaired CBF autoregulation in the infarcted hemisphere.
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Affiliation(s)
- Turgut Durduran
- Departments of Radiology, University of Pennsylvania, PA, USA.
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