1
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McDevitt WM, Farley M, Martin-Lamb D, Jones TJ, Morris KP, Seri S, Scholefield BR. Feasibility of non-invasive neuro-monitoring during extracorporeal membrane oxygenation in children. Perfusion 2023; 38:547-556. [PMID: 35212252 DOI: 10.1177/02676591211066804] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
INTRODUCTION Detection of neurological complications during extracorporeal membrane oxygenation (ECMO) may be enhanced with non-invasive neuro-monitoring. We investigated the feasibility of non-invasive neuro-monitoring in a paediatric intensive care (PIC) setting. METHODS In a single centre, prospective cohort study we assessed feasibility of recruitment, and neuro-monitoring via somatosensory evoked potentials (SSEP), electroencephalography (EEG) and near infrared spectroscopy (NIRS) during venoarterial (VA) ECMO in paediatric patients (0-15 years). Measures were obtained within 24h of cannulation, during an intermediate period, and finally at decannulation or echo stress testing. SSEP/EEG/NIRS measures were correlated with neuro-radiology findings, and clinical outcome assessed via the Pediatric cerebral performance category (PCPC) scale 30 days post ECMO cannulation. RESULTS We recruited 14/20 (70%) eligible patients (median age: 9 months; IQR:4-54, 57% male) over an 18-month period, resulting in a total of 42 possible SSEP/EEG/NIRS measurements. Of these, 32/42 (76%) were completed. Missed recordings were due to lack of access/consent within 24 h of cannulation (5/42, 12%) or PIC death/discharge (5/42, 12%). In each patient, the majority of SSEP (8/14, 57%), EEG (8/14, 57%) and NIRS (11/14, 79%) test results were within normal limits. All patients with abnormal neuroradiology (4/10, 40%), and 6/7 (86%) with poor outcome (PCPC ≥4) developed indirect SSEP, EEG or NIRS measures of neurological complications prior to decannulation. No study-related adverse events or neuro-monitoring data interpreting issues were experienced. CONCLUSION Non-invasive neuro-monitoring (SSEP/EEG/NIRS) during ECMO is feasible and may provide early indication of neurological complications in this high-risk population.
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Affiliation(s)
- William M McDevitt
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Margaret Farley
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK
| | - Darren Martin-Lamb
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK
| | - Timothy J Jones
- Department of Cardiac Surgery, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Cardiovascular Sciences, University of Birmingham, Birmingham, UK
| | - Kevin P Morris
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Institute of Applied Health Research, University of Birmingham, Birmingham, UK
| | - Stefano Seri
- Department of Neurophysiology, 156630Birmingham Children's Hospital Birmingham, UK.,Aston Brain Centre, School of Life and Health Sciences, Aston University, Birmingham, UK
| | - Barnaby R Scholefield
- Paediatric Intensive Care Unit, 156630Birmingham Children's Hospital, Birmingham, UK.,Birmingham Acute Care Research Group, Institute of Inflammation and Ageing, University of Birmingham, Birmingham, UK
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2
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Spalletti M, Orzalesi V, Carrai R, Bucciardini L, Cossu C, Scarpino M, Fainardi E, Marinoni M, Grippo A, Amantini A. Amplitude Instability of Somatosensory Evoked Potentials as an Indicator of Delayed Cerebral Ischemia in a Case of Subarachnoid Hemorrhage. Clin EEG Neurosci 2019; 50:205-209. [PMID: 30280591 DOI: 10.1177/1550059418804915] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/15/2022]
Abstract
We describe a 55-year-old male patient with a subarachnoid hemorrhage (SAH) as a result of left middle cerebral artery (MCA) aneurysm rupture, who underwent continuous electroencephalogram (EEG) and somatosensory evoked potential (cEEG-SEP) monitoring that showed an unusual SEP trend pattern. EEG was continuously recorded, and SEPs following stimulation of median nerves were recorded every 50 minutes, with the amplitude and latency of the cortical components automatically trended. An increase in intracranial pressure required a left decompressive craniectomy. cEEG-SEP monitoring was started on day 7, which showed a prolonged (24 hours) instability of SEPs in the left hemisphere. During this phase, left MCA vasospasm was demonstrated by transcranial Doppler (TCD), and computed tomography perfusion (CTP) showed a temporo-parieto-occipital ischemic penumbra. Following intravascular treatment, hypoperfusion and the amplitude of cortical SEPs improved. In our case, a prolonged phase of SEP amplitude instability during vasospasm in SAH correlated with a phase of ischemic penumbra, as demonstrated by CTP. In SAH, SEP instability during continuous monitoring is a pattern of alert that can allow treatments capable of avoiding irreversible neurological deterioration.
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Affiliation(s)
- Maddalena Spalletti
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy
| | - Vanni Orzalesi
- 2 SOD Neuroanestesia e Rianimazione, Dipartimento di Anestesia e Rianimazione, AOU Careggi, Florence, Italy
| | - Riccardo Carrai
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy.,3 IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Luca Bucciardini
- 2 SOD Neuroanestesia e Rianimazione, Dipartimento di Anestesia e Rianimazione, AOU Careggi, Florence, Italy
| | - Cesarina Cossu
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy
| | - Maenia Scarpino
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy.,3 IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Enrico Fainardi
- 4 SOD Neuroradiologia, AOU Careggi, Florence, Italy.,5 Dipartimento di Scienze Biomediche Cliniche e Sperimentali "Mario Serio", Università degli Studi di Firenze, Florence, Italy
| | - Marinella Marinoni
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy.,6 Unit Neurosonologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy
| | - Antonello Grippo
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy.,3 IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
| | - Aldo Amantini
- 1 SOD Neurofisiopatologia, Dipartimento Neuromuscoloscheletrico e Organi di Senso, AOU Careggi, Florence, Italy.,3 IRCCS, Fondazione Don Carlo Gnocchi, Florence, Italy
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3
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Scarpino M, Carrai R, Lolli F, Lanzo G, Spalletti M, Audenino D, Callegarin C, Celani MG, Lombardi M, Marrelli A, Mecarelli O, Minardi C, Minicucci F, Motti L, Politini L, Valzania F, Vitelli E, Peris A, Amantini A, Grippo A. Electroencephalogram and somatosensory evoked potential evaluation for good and poor neurological prognosis after cardiac arrest: a prospective multicenter cohort trial (ProNeCA). FUTURE NEUROLOGY 2019. [DOI: 10.2217/fnl-2018-0036] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/15/2023]
Abstract
Aim: Hypoxic-ischemic-encephalopathy is a severe and frequent neurological complication of successful cardiopulmonary-resuscitation after cardiac arrest. Prognosticating neurological outcomes in patients with hypoxic-ischemic-encephalopathy is challenging and recent guidelines suggest a multimodal approach. Only few studies have analyzed the prognostic power of the association between instrumental tests and, in addition, most of them were monocentric, retrospective and evaluating only poor outcome. Methods/design: We designed a multicenter prospective cohort study to assessing the prognostic power of the association of electroencephalogram and somatosensory evoked potentials for the prediction of both poor and good neurological outcomes at different times after cardiac arrest. Discussion: The results of our study will provide a high level of evidence for the use of neurophysiological evaluation in the current clinical practice.
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Affiliation(s)
| | - Riccardo Carrai
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Francesco Lolli
- Dipartimento di Scienze Biomediche Sperimentali e Cliniche, Università degli studi di Firenze, Italy
| | - Giovanni Lanzo
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Maddalena Spalletti
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | | | - Claudio Callegarin
- UO Neurologia e Neurofisiopatologia, Ospedale Santa Maria delle Croci, Ravenna, Italy
| | - Maria Grazia Celani
- UO Neurofisiopatologia, Ospedale Santa Maria della Misericordia, Perugia, Italy
| | | | - Alfonso Marrelli
- UOC Neurofisiopatologia, Ospedale San Salvatore, L’Aquila, Italy
| | - Oriano Mecarelli
- UOC Neurofisiopatologia, Policlinico Umberto primo, Università La Sapienza, Roma, Italy
| | | | - Fabio Minicucci
- UO Neurofisiopatologia, Ospedale San Raffaele IRCCS, Milano, Italy
| | - Luisa Motti
- UO Neurofisiopatologia Arcispedale. Santa Maria Nuova, Reggio nell’Emilia, Italy
| | | | - Franco Valzania
- Neurofisiopatologia Interventiva, Osp Civile di Baggiovara, Modena, Italy
| | | | - Adriano Peris
- SODc Cure intensive per il trauma ed i supporti extracorporei, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Aldo Amantini
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
| | - Antonello Grippo
- IRCCS Fondazione Don Carlo Gnocchi, Firenze, Italy
- SODc Neurofisiopatologia, Dipartimento Neuromuscolo-Scheletrico e degli Organi di Senso, AOU Careggi, Firenze, Italy
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4
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Azabou E, Rohaut B, Porcher R, Heming N, Kandelman S, Allary J, Moneger G, Faugeras F, Sitt JD, Annane D, Lofaso F, Chrétien F, Mantz J, Naccache L, Sharshar T. Mismatch negativity to predict subsequent awakening in deeply sedated critically ill patients. Br J Anaesth 2018; 121:1290-1297. [PMID: 30442256 DOI: 10.1016/j.bja.2018.06.029] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2018] [Revised: 06/14/2018] [Accepted: 06/27/2018] [Indexed: 01/11/2023] Open
Abstract
BACKGROUND Mismatch negativity (MMN) is the neurophysiological correlate of cognitive integration of novel stimuli. Although MMN is a well-established predictor of awakening in non-sedated comatose patients, its prognostic value in deeply sedated critically ill patients remains unknown. The aim of this prospective, observational pilot study was to investigate the prognostic value of MMN for subsequent awakening in deeply sedated critically ill patients. METHODS MMN was recorded in 43 deeply sedated critically ill patients on Day 3 of ICU admission using a classical 'odd-ball' paradigm that delivers rare deviant sounds in a train of frequent standard sounds. Individual visual analyses and a group level analysis of recordings were performed. MMN amplitudes were then analysed according to the neurological status (awake vs not awake) at Day 28. RESULTS Median (inter-quartile range) Richmond Assessment Sedation Scale (RASS) at the time of recording was -5 (range, from -5 to -4.5). Visual detection of MMN revealed a poor inter-rater agreement [kappa=0.17, 95% confidence interval (0.07-0.26)]. On Day 28, 30 (70%) patients had regained consciousness while 13 (30%) had not. Quantitative group level analysis revealed a significantly greater MMN amplitude for patients who awakened compared with those who had not [mean (standard deviation) = -0.65 (1.4) vs 0.08 (0.17) μV, respectively; P=0.003). CONCLUSIONS MMN can be observed in deeply sedated critically ill patients and could help predict subsequent awakening. However, visual analysis alone is unreliable and should be systematically completed with individual level statistics.
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Affiliation(s)
- E Azabou
- Department of Physiology, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1179, University of Versailles Saint-Quentin en Yvelines, Garches, Paris, France; General Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - B Rohaut
- Department of Neurology, Neuro-ICU, Columbia University, New York, NY, USA
| | - R Porcher
- Center for Clinical Epidemiology, Assistance Publique-Hôpitaux de Paris, Hotel Dieu Hospital, University Paris Descartes, INSERM U1153, Paris, France
| | - N Heming
- General Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - S Kandelman
- Department of Anesthesiology and Intensive Care Medicine, Beaujon Hospital, University of Denis Diderot, Clichy, France
| | - J Allary
- Department of Anesthesiology and Intensive Care Medicine, Beaujon Hospital, University of Denis Diderot, Clichy, France
| | - G Moneger
- General Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - F Faugeras
- Institut du Cerveau et de la Moelle épinière, Paris, France
| | - J D Sitt
- Institut du Cerveau et de la Moelle épinière, Paris, France
| | - D Annane
- General Intensive Care Unit, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - F Lofaso
- Department of Physiology, Assistance Publique-Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1179, University of Versailles Saint-Quentin en Yvelines, Garches, Paris, France
| | - F Chrétien
- Laboratory of Experimental Neuropathology, Institut Pasteur, Paris, France
| | - J Mantz
- Laboratory of Experimental Neuropathology, Institut Pasteur, Paris, France; Department of Anesthesiology and Intensive Care Medicine, European Hospital Georges Pompidou, Paris Descartes University, Paris, France
| | - L Naccache
- Institut du Cerveau et de la Moelle épinière, Paris, France
| | - T Sharshar
- Laboratory of Experimental Neuropathology, Institut Pasteur, Paris, France; Department of Neuro-Intensive Care Medicine, Sainte-Anne Hospital, Paris-Descartes University, Paris, France; Laboratoire de Neuropathologie Expérimentale, Institut Pasteur, Paris, France.
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5
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Scarpino M, Lanzo G, Lolli F, Carrai R, Moretti M, Spalletti M, Cozzolino M, Peris A, Amantini A, Grippo A. Neurophysiological and neuroradiological multimodal approach for early poor outcome prediction after cardiac arrest. Resuscitation 2018; 129:114-120. [DOI: 10.1016/j.resuscitation.2018.04.016] [Citation(s) in RCA: 48] [Impact Index Per Article: 8.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2017] [Revised: 04/07/2018] [Accepted: 04/14/2018] [Indexed: 01/09/2023]
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6
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Noninvasive Neuromonitoring: Current Utility in Subarachnoid Hemorrhage, Traumatic Brain Injury, and Stroke. Neurocrit Care 2018; 27:122-140. [PMID: 28004334 DOI: 10.1007/s12028-016-0361-8] [Citation(s) in RCA: 32] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
Noninvasive neuromonitoring is increasingly being used to monitor the course of primary brain injury and limit secondary brain damage of patients in the neurocritical care unit. Proposed advantages over invasive neuromonitoring methods include a lower risk of infection and bleeding, no need for surgical installation, mobility and portability of some devices, and safety. The question, however, is whether noninvasive neuromonitoring is practical and trustworthy enough already. We searched the recent literature and reviewed English-language studies on noninvasive neuromonitoring in subarachnoid hemorrhage, traumatic brain injury, and ischemic and hemorrhagic stroke between the years 2010 and 2015. We found 88 studies that were eligible for review including the methods transcranial ultrasound, electroencephalography, evoked potentials, near-infrared spectroscopy, bispectral index, and pupillometry. Noninvasive neuromonitoring cannot yet completely replace invasive methods in most situations, but has great potential being complementarily integrated into multimodality monitoring, for guiding management, and for limiting the use of invasive devices and in-hospital transports for imaging.
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7
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Stone JL, Bailes JE, Hassan AN, Sindelar B, Patel V, Fino J. Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring. Neurocrit Care 2017; 26:143-156. [PMID: 27484878 DOI: 10.1007/s12028-016-0298-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/07/2023]
Abstract
Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.
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Affiliation(s)
- James L Stone
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA. .,Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA. .,Division of Neurosurgery, Department of Surgery, Cook County Stroger Hospital, Chicago, IL, USA.
| | - Julian E Bailes
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - Ahmed N Hassan
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
| | - Brian Sindelar
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.,Department of Neurosurgery, University of Florida, Gainesville, FL, USA
| | - Vimal Patel
- Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA
| | - John Fino
- Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA
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8
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Azabou E, Rohaut B, Heming N, Magalhaes E, Morizot-Koutlidis R, Kandelman S, Allary J, Moneger G, Polito A, Maxime V, Annane D, Lofaso F, Chrétien F, Mantz J, Porcher R, Sharshar T. Early impairment of intracranial conduction time predicts mortality in deeply sedated critically ill patients: a prospective observational pilot study. Ann Intensive Care 2017; 7:63. [PMID: 28608136 PMCID: PMC5468361 DOI: 10.1186/s13613-017-0290-5] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/11/2017] [Accepted: 06/02/2017] [Indexed: 12/21/2022] Open
Abstract
Background Somatosensory (SSEP) and brainstem auditory (BAEP) evoked potentials are neurophysiological tools which, respectively, explore the intracranial conduction time (ICCT) and the intrapontine conduction time (IPCT). The prognostic values of prolonged cerebral conduction times in deeply sedated patients have never been assessed. Sedated patients are at risk of developing new neurological complications, undetected. In this prospective observational bi-center pilot study, we investigated whether early impairment of SSEP’s ICCT and/or BAEP’s IPCT could predict in-ICU mortality or altered mental status (AMS), in deeply sedated critically ill patients. Methods SSEP by stimulation of the median nerve and BAEP were assessed in critically ill patients receiving deep sedation on day 3 following ICU admission. Deep sedation was defined by a Richmond Assessment sedation Scale (RASS) <−3. Mean left- and right-side ICCT and IPCT were measured for each patient. Primary and secondary outcomes were, respectively, in-ICU mortality and AMS defined as the occurrence of delirium and/or delayed awakening after discontinuation of sedation. Results Eighty-six patients were studied of which 49 (57%) were non-brain-injured and 37 (43%) were brain-injured. Impaired ICCT was a predictor of in-ICU mortality after adjustment on the global Sequential Organ Failure Assessment score (SOFA) [OR (95% CI) = 2.69 (1.05–6.85); p = 0.039] and on the non-neurological SOFA components [2.67 (1.05–6.81); p = 0.040]. IPCT was more frequently delayed in the subgroup of patients who developed post-sedation AMS (24%) compared those without AMS (0%). However, this difference did not reach statistical significance (p = 0.053). Impairment rates of ICCT and IPCT were not found to be significantly different between non-brain- and brain-injured subgroups of patients. Conclusion In critically ill patients receiving deep sedation, early ICCT impairment was associated with mortality. Somatosensory and brainstem auditory evoked potentials may be useful early warning indicators of brain dysfunction as well as prognostic markers in deeply sedated critically ill patients.
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Affiliation(s)
- Eric Azabou
- Department of Physiology - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1179, University of Versailles Saint-Quentin en Yvelines, Garches, France.,General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Benjamin Rohaut
- Department of Neurology, Intensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.,UPMC Univ. Paris 06, Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, Paris, France
| | - Nicholas Heming
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Eric Magalhaes
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Régine Morizot-Koutlidis
- Department of Neurology, Intensive Care Unit, Groupe Hospitalier Pitié-Salpêtrière, AP-HP, Paris, France.,UPMC Univ. Paris 06, Faculté de Médecine Pitié-Salpêtrière, Sorbonne Universités, Paris, France
| | - Stanislas Kandelman
- Department of Anesthesiology and Intensive Care Medicine - Beaujon Hospital, University of Denis Diderot, Clichy, France
| | - Jeremy Allary
- Department of Anesthesiology and Intensive Care Medicine - Beaujon Hospital, University of Denis Diderot, Clichy, France
| | - Guy Moneger
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Andrea Polito
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Virginie Maxime
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Djillali Annane
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Frederic Lofaso
- Department of Physiology - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1179, University of Versailles Saint-Quentin en Yvelines, Garches, France
| | - Fabrice Chrétien
- Laboratory of Human Histopathology and Animal Models, Institut Pasteur, 28, rue du Dr Roux, 75015, Paris, France
| | - Jean Mantz
- Laboratory of Human Histopathology and Animal Models, Institut Pasteur, 28, rue du Dr Roux, 75015, Paris, France.,Department of Anesthesiology and Intensive Care Medicine - European Hospital Georges Pompidou, Paris Descartes University, Paris, France
| | - Raphael Porcher
- Center for Clinical Epidemiology - Assistance Publique Hôpitaux de Paris, Hotel Dieu Hospital, INSERM U1153, University Paris Descartes, Paris, France
| | - Tarek Sharshar
- General Intensive Care Unit - Assistance Publique Hôpitaux de Paris, Raymond-Poincaré Hospital, INSERM U 1173, University of Versailles Saint-Quentin en Yvelines, Garches, France. .,Laboratory of Human Histopathology and Animal Models, Institut Pasteur, 28, rue du Dr Roux, 75015, Paris, France. .,General Intensive Care Medicine, Raymond Poincaré Hospital (AP-HP), University of Versailles Saint-Quentin en Yvelines, 104, Boulevard Raymond Poincaré, 92380, Garches, France.
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9
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Scarpino M, Lanzo G, Carrai R, Lolli F, Migliaccio ML, Spalletti M, Peris A, Amantini A, Grippo A. Predictive patterns of sensory evoked potentials in comatose brain injured patients evolving to brain death. Neurophysiol Clin 2017; 47:19-29. [DOI: 10.1016/j.neucli.2016.11.001] [Citation(s) in RCA: 17] [Impact Index Per Article: 2.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/31/2016] [Accepted: 11/22/2016] [Indexed: 10/20/2022] Open
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10
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Easily applicable SEP-monitoring of the N20 wave in the intensive care unit. Neurophysiol Clin 2017; 47:31-34. [PMID: 28153716 DOI: 10.1016/j.neucli.2017.01.004] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/05/2016] [Accepted: 01/05/2017] [Indexed: 12/28/2022] Open
Abstract
In this technical note, a conveniently sized, single-channel somatosensory evoked potentials (SEP)-stimulation-recording unit for bedside use in the intensive care unit is presented. The validation of the SEP N20 wave in intensive care guidelines as initial parameter for the prognostic evaluation of cardiac arrest has increased the demand for a more widespread availability of SEP, outside the electrophysiological domain. A device with a simplified interface that safely guides the user through a complete examination and that includes artifact removal is a prerequisite for such more widespread use, in which expert interpretation can be reduced to a necessary minimum.
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11
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Neurophysiological assessment of brain dysfunction in critically ill patients: an update. Neurol Sci 2017; 38:715-726. [PMID: 28110410 DOI: 10.1007/s10072-017-2824-x] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2016] [Accepted: 01/16/2017] [Indexed: 01/08/2023]
Abstract
The aim of this review was to provide up-to-date information about the usefulness of clinical neurophysiology testing in the management of critically ill patients. Evoked potentials (EPs) and electroencephalogram (EEG) are non-invasive clinical neurophysiology tools that allow an objective assessment of the central nervous system's function at the bedside in intensive care unit (ICU). These tests are quite useful in diagnosing cerebral complications, and establishing the vital and functional prognosis in ICU. EEG keeps a particularly privileged importance in detecting seizures phenomena such as subclinical seizures and non-convulsive status epilepticus. Quantitative EEG (QEEG) analysis techniques commonly called EEG Brain mapping can provide obvious topographic displays of digital EEG signals characteristics, showing the potential distribution over the entire scalp including filtering, frequency, and amplitude analysis and color mapping. Evidences of usefulness of QEEG for seizures detection in ICU are provided by several recent studies. Furthermore, beyond detection of epileptic phenomena, changes of some QEEG panels are early warning indicators of sedation level as well as brain damage or dysfunction in ICU. EPs offer the opportunity for assessing brainstem's functional integrity, as well as subcortical and cortical brain areas. A multimodal use, combining EEG and various modalities of EPs is recommended since this allows a more accurate functional exploration of the brain and helps caregivers to tailor therapeutic measures according to neurological worsening trends and to anticipate the prognosis in ICU.
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Abstract
To determine the optimal use and indications of electroencephalography (EEG) in critical care management of acute brain injury (ABI). An electronic literature search was conducted for articles in English describing electrophysiological monitoring in ABI from January 1990 to August 2013. A total of 165 studies were included. EEG is a useful monitor for seizure and ischemia detection. There is a well-described role for EEG in convulsive status epilepticus and cardiac arrest (CA). Data suggest EEG should be considered in all patients with ABI and unexplained and persistent altered consciousness and in comatose intensive care unit (ICU) patients without an acute primary brain condition who have an unexplained impairment of mental status. There remain uncertainties about certain technical details, e.g., the minimum duration of EEG studies, the montage, and electrodes. Data obtained from both EEG and EP studies may help estimate prognosis in ABI patients, particularly following CA and traumatic brain injury. Data supporting these recommendations is sparse, and high quality studies are needed. EEG is used to monitor and detect seizures and ischemia in ICU patients and indications for EEG are clear for certain disease states, however, uncertainty remains on other applications.
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Ordek G, Proddutur A, Santhakumar V, Pfister BJ, Sahin M. Electrophysiological monitoring of injury progression in the rat cerebellar cortex. Front Syst Neurosci 2014; 8:197. [PMID: 25346664 PMCID: PMC4191519 DOI: 10.3389/fnsys.2014.00197] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/20/2014] [Accepted: 09/23/2014] [Indexed: 12/05/2022] Open
Abstract
The changes of excitability in affected neural networks can be used as a marker to study the temporal course of traumatic brain injury (TBI). The cerebellum is an ideal platform to study brain injury mechanisms at the network level using the electrophysiological methods. Within its crystalline morphology, the cerebellar cortex contains highly organized topographical subunits that are defined by two main inputs, the climbing (CFs) and mossy fibers (MFs). Here we demonstrate the use of cerebellar evoked potentials (EPs) mediated through these afferent systems for monitoring the injury progression in a rat model of fluid percussion injury (FPI). A mechanical tap on the dorsal hand was used as a stimulus, and EPs were recorded from the paramedian lobule (PML) of the posterior cerebellum via multi-electrode arrays (MEAs). Post-injury evoked response amplitudes (EPAs) were analyzed on a daily basis for 1 week and compared with pre-injury values. We found a trend of consistently decreasing EPAs in all nine animals, losing as much as 72 ± 4% of baseline amplitudes measured before the injury. Notably, our results highlighted two particular time windows; the first 24 h of injury in the acute period and day-3 to day-7 in the delayed period where the largest drops (~50% and 24%) were observed in the EPAs. In addition, cross-correlations of spontaneous signals between electrode pairs declined (from 0.47 ± 0.1 to 0.35 ± 0.04, p < 0.001) along with the EPAs throughout the week of injury. In support of the electrophysiological findings, immunohistochemical analysis at day-7 post-injury showed detectable Purkinje cell loss at low FPI pressures and more with the largest pressures used. Our results suggest that sensory evoked potentials (SEPs) recorded from the cerebellar surface can be a useful technique to monitor the course of cerebellar injury and identify the phases of injury progression even at mild levels.
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Affiliation(s)
- Gokhan Ordek
- Department of Biomedical Engineering, New Jersey Institute of Technology Newark, NJ, USA
| | - Archana Proddutur
- Department of Neurology and Neurosciences, Rutgers Biomedical and Health Sciences Newark, NJ, USA
| | | | - Bryan J Pfister
- Department of Biomedical Engineering, New Jersey Institute of Technology Newark, NJ, USA
| | - Mesut Sahin
- Department of Biomedical Engineering, New Jersey Institute of Technology Newark, NJ, USA
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Abstract
The science of nursing has long been discussed as a blending of the art and science of caring, and nursing research builds the evidence of support for nursing practice. Nurses and nursing care are key to successful neurocritical care research endeavors. Ideally nursing care should be evidence based and supported by solid research. The goal of nursing research is to expand the knowledge of caring for patients. Within the scope of nursing research, the priorities for research in neurocritical care should support this goal. In this manuscript, we discuss what we believe are the priorities of neurocritical care nursing research, the obstacles, and some possible solutions.
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Yan Y, Tang W, Deng Z, Zhong D, Yang G. Cerebral oxygen metabolism and neuroelectrophysiology in a clinical study of severe brain injury and mild hypothermia. J Clin Neurosci 2010; 17:196-200. [DOI: 10.1016/j.jocn.2009.05.022] [Citation(s) in RCA: 16] [Impact Index Per Article: 1.1] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/19/2009] [Revised: 04/06/2009] [Accepted: 05/17/2009] [Indexed: 10/20/2022]
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Wendel K, Väisänen J, Seemann G, Hyttinen J, Malmivuo J. The influence of age and skull conductivity on surface and subdermal bipolar EEG leads. COMPUTATIONAL INTELLIGENCE AND NEUROSCIENCE 2010; 2010:397272. [PMID: 20130812 PMCID: PMC2814227 DOI: 10.1155/2010/397272] [Citation(s) in RCA: 49] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/01/2009] [Accepted: 10/08/2009] [Indexed: 11/17/2022]
Abstract
Bioelectric source measurements are influenced by the measurement location as well as the conductive properties of the tissues. Volume conductor effects such as the poorly conducting bones or the moderately conducting skin are known to affect the measurement precision and accuracy of the surface electroencephalography (EEG) measurements. This paper investigates the influence of age via skull conductivity upon surface and subdermal bipolar EEG measurement sensitivity conducted on two realistic head models from the Visible Human Project. Subdermal electrodes (a.k.a. subcutaneous electrodes) are implanted on the skull beneath the skin, fat, and muscles. We studied the effect of age upon these two electrode types according to the scalp-to-skull conductivity ratios of 5, 8, 15, and 30 : 1. The effects on the measurement sensitivity were studied by means of the half-sensitivity volume (HSV) and the region of interest sensitivity ratio (ROISR). The results indicate that the subdermal implantation notably enhances the precision and accuracy of EEG measurements by a factor of eight compared to the scalp surface measurements. In summary, the evidence indicates that both surface and subdermal EEG measurements benefit better recordings in terms of precision and accuracy on younger patients.
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Affiliation(s)
- Katrina Wendel
- 1Department of Biomedical Engineering, Tampere University of Technology, Korkeakoulunkatu 3, P.O. Box 692, 33101 Tampere, Finland
- *Katrina Wendel:
| | - Juho Väisänen
- 1Department of Biomedical Engineering, Tampere University of Technology, Korkeakoulunkatu 3, P.O. Box 692, 33101 Tampere, Finland
| | - Gunnar Seemann
- 2Institute of Biomedical Engineering, Karlsruhe Institute of Technology, 76131 Karlsruhe, Germany
| | - Jari Hyttinen
- 1Department of Biomedical Engineering, Tampere University of Technology, Korkeakoulunkatu 3, P.O. Box 692, 33101 Tampere, Finland
| | - Jaakko Malmivuo
- 1Department of Biomedical Engineering, Tampere University of Technology, Korkeakoulunkatu 3, P.O. Box 692, 33101 Tampere, Finland
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Guerit JM, Amantini A, Fischer C, Kaplan PW, Mecarelli O, Schnitzler A, Ubiali E, Amodio P. Neurophysiological investigations of hepatic encephalopathy: ISHEN practice guidelines. Liver Int 2009; 29:789-96. [PMID: 19638107 DOI: 10.1111/j.1478-3231.2009.02030.x] [Citation(s) in RCA: 93] [Impact Index Per Article: 6.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
By studying neuronal activity through neuronal electrogenesis, neurophysiological investigations provide a functional assessment of the nervous system and, therefore, has been used for quantitative assessment and follow-up of hepatic encephalopathy (HE). The different clinical neurophysiological approaches can be classified depending on the function to explore and their sensitivity to HE. The reliable techniques are those that reflect cortical function, i.e., cognitive-evoked potentials (EPs) (P300 paradigm), electroencephalogram (EEG), visual EPs (latency>100 ms) and somatosensory EPs (SEPs) (latency between 25 and 100 ms). Short-latency EPs (brainstem acoustic EPs, SEPs of a latency<25 ms) are in principle insensitive to HE, but can disclose brainstem conduction deficits due to oedema. SEPs and motor EPs can disclose myelopathies. Because of its parallelism to the clinical examination, clinical neurophysiology can complement the neurological examination: (i) to provide evidence of HE in patients who have normal consciousness; (ii) to rule out, at least under some conditions, disturbances of consciousness due to other causes (e.g. drug-induced disturbances, non-convulsive status epilepticus) with the reservation that the mildest degrees of encephalopathy might be associated with an EEG pattern similar to that induced by drugs; and (iii) to demonstrate the worsening or, conversely improvement, of HE in the follow-up period.
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Martz GU, Hucek C, Quigg M. Sixty Day Continuous Use of Subdermal Wire Electrodes for EEG Monitoring During Treatment of Status Epilepticus. Neurocrit Care 2009; 11:223-7. [DOI: 10.1007/s12028-009-9215-y] [Citation(s) in RCA: 14] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/13/2008] [Accepted: 03/31/2009] [Indexed: 12/01/2022]
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Guérit JM, Amantini A, Amodio P, Andersen K, Butler S, de Weerd A, Facco E, Fischer C, Hantson P, Jäntti V, Lamblin MD, Litscher G, Péréon Y. Consensus on the use of neurophysiological tests in the intensive care unit (ICU): Electroencephalogram (EEG), evoked potentials (EP), and electroneuromyography (ENMG). Neurophysiol Clin 2009; 39:71-83. [DOI: 10.1016/j.neucli.2009.03.002] [Citation(s) in RCA: 65] [Impact Index Per Article: 4.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/22/2009] [Accepted: 03/28/2009] [Indexed: 10/20/2022] Open
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Amantini A, Fossi S, Grippo A, Innocenti P, Amadori A, Bucciardini L, Cossu C, Nardini C, Scarpelli S, Roma V, Pinto F. Continuous EEG-SEP monitoring in severe brain injury. Neurophysiol Clin 2009; 39:85-93. [PMID: 19467438 DOI: 10.1016/j.neucli.2009.01.006] [Citation(s) in RCA: 45] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2008] [Revised: 01/07/2009] [Accepted: 01/18/2009] [Indexed: 02/06/2023] Open
Abstract
AIMS To monitor acute brain injury in the neurological intensive care unit (NICU), we used EEG and somatosensory evoked potentials (SEP) in combination to achieve more accuracy in detecting brain function deterioration. METHODS Sixty-eight patients (head trauma and intracranial hemorrhage; GCS<9) were monitored with continuous EEG-SEP and intracranial pressure monitoring (ICP). RESULTS Fifty-five patients were considered "stable" or improving, considering the GCS and CT scan: in this group, SEP didn't show significant changes. Thirteen patients showed neurological deteriorations and, in all patients, cortical SEP showed significant alterations (amplitude decrease>50% often till complete disappearance). SEP deterioration anticipated ICP increase in 30%, was contemporary in 38%, and followed ICP increase in 23%. Considering SEP and ICP in relation to clinical course, all patients but one with ICP less than 20 mmHg were stable, while the three patients with ICP greater than 40 mmHg all died. Among the 26 patients with ICP of 20-40 mmHg, 17 were stable, while nine showed clinical and neurophysiological deterioration. Thus, there is a range of ICP values (20-40 mmHg) were ICP is scarcely indicative of clinical deterioration, rather it is the SEP changes that identify brain function deterioration. Therefore, SEP have a twofold interest with respect to ICP: their changes can precede an ICP increase and they can constitute a complementary tool to interpret ICP trends. It has been very important to associate SEP and EEG: about 60% of our patients were deeply sedated and, because of their relative insensitivity to anesthetics, only SEP allowed us to monitor brain damage evolution when EEG was scarcely valuable. CONCLUSIONS We observed 3% of nonconvulsive status epilepticus compared to 18% of neurological deterioration. If the aim of neurophysiological monitoring is to "detect and protect", it may not be limited to detecting seizures, rather it should be able to identify brain deterioration, so we propose the combined monitoring of EEG with SEP.
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Affiliation(s)
- A Amantini
- Unit of Clinical Neurophysiology, DAI Neurological Sciences, University of Florence - Az., Ospedaliero Universitaria Careggi, V. le Morgagni 85, 50134 Florence, Italy.
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Abstract
The most informative neurophysiological techniques available in the neurosurgical intensive care unit are electroencephalograph and somatosensory evoked potentials. Such tools, which give an evaluation of cerebral function in comatose patients, support clinical evaluation and are complementary to neuroimaging. They serve both diagnostic/prognostic and monitoring purposes. While for the former, discontinuous monitoring is sufficient, for the latter, to obtain increased clinical impact, continuous monitoring is necessary. To perform and interpret these examinations in the neurosurgical intensive care unit, both the technician and the neurophysiologist need specific training in the intensive care field. There is sufficient evidence to show that somatosensory evoked potentials are the best single indicator of early prognosis in traumatic and hypoxic-ischaemic coma compared to the Glasgow Coma Score, computed tomography scan and electroencephalograph. Indeed, somatosensory evoked potentials should always be combined with clinical examination to determine the prognosis of coma. Despite widespread use of somatosensory evoked potentials and their prognostic utility in acute brain injury, few studies exist on continuous somatosensory evoked potential monitoring in the intensive care unit. We carried out a pilot study of continuous electroencephalograph-somatosensory evoked potential monitoring in the neurosurgical intensive care unit (traumatic brain injury and intracranial haemorrhage, Glasgow Coma Score <9, intracranial pressure monitoring). All patients stable from a clinical and computed tomography scan point of view showed no significant somatosensory evoked potential modifications, while in the case of clinical deterioration (23%), somatosensory evoked potentials always showed significant modifications. While somatosensory evoked potentials correlated with short-term outcome, intracranial pressure showed a poor correlation. We believe neurophysiological monitoring is an ideal complement to the other parameters monitored in the neurosurgical intensive care unit. Whereas intracranial pressure is simply a pressure index, electroencephalograph-somatosensory evoked potential monitoring reflects to what extent cerebral parenchyma still remains metabolically active during acute brain injury.
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22
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Cruccu G, Aminoff MJ, Curio G, Guerit JM, Kakigi R, Mauguiere F, Rossini PM, Treede RD, Garcia-Larrea L. Recommendations for the clinical use of somatosensory-evoked potentials. Clin Neurophysiol 2008; 119:1705-1719. [PMID: 18486546 DOI: 10.1016/j.clinph.2008.03.016] [Citation(s) in RCA: 426] [Impact Index Per Article: 26.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2007] [Revised: 03/20/2008] [Accepted: 03/20/2008] [Indexed: 12/20/2022]
Abstract
The International Federation of Clinical Neurophysiology (IFCN) is in the process of updating its Recommendations for clinical practice published in 1999. These new recommendations dedicated to somatosensory-evoked potentials (SEPs) update the methodological aspects and general clinical applications of standard SEPs, and introduce new sections dedicated to the anatomical-functional organization of the somatosensory system and to special clinical applications, such as intraoperative monitoring, recordings in the intensive care unit, pain-related evoked potentials, and trigeminal and pudendal SEPs. Standard SEPs have gained an established role in the health system, and the special clinical applications we describe here are drawing increasing interest. However, to prove clinically useful each of them requires a dedicated knowledge, both technical and pathophysiological. In this article we give technical advice, report normative values, and discuss clinical applications.
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Affiliation(s)
- G Cruccu
- Department of Neurological Sciences, La Sapienza University, viale Università 30, 00185 Rome, Italy.
| | - M J Aminoff
- Department of Neurology, School of Medicine, University of California, San Francisco, CA, USA
| | - G Curio
- Department of Neurology and Clinical Neurophysiology, Campus Benjamin Franklin, Charité - University Medicine Berlin, Berlin, Germany
| | - J M Guerit
- Neurology, Clinical Neurophysiology Unit, CHIREC, Brussels, Belgium
| | - R Kakigi
- Department of Integrative Physiology, National Institute for Physiological Sciences, Okazaki, Japan
| | - F Mauguiere
- Université de Lyon 1, Lyon, France; INSERM U879 - Central Integration of Pain Unit, Neurological Hospital Lyon, France
| | - P M Rossini
- Neurology, Università Campus Bio-Medico, Rome, Italy; IRCCS, S.Giovanni di Dio, Fatebenefratelli, Brescia, Italy
| | - R-D Treede
- Institute of Physiology and Pathophysiology, Johannes Gutenberg University, Mainz, Germany
| | - L Garcia-Larrea
- Université de Lyon 1, Lyon, France; INSERM U879 - Central Integration of Pain Unit, Neurological Hospital Lyon, France
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23
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Abstract
Multimodality monitoring of cerebral physiology encompasses the application of different monitoring techniques and integration of several measured physiologic and biochemical variables into assessment of brain metabolism, structure, perfusion, and oxygenation status. Novel monitoring techniques include transcranial Doppler ultrasonography, neuroimaging, intracranial pressure, cerebral perfusion, and cerebral blood flow monitors, brain tissue oxygen tension monitoring, microdialysis, evoked potentials, and continuous electroencephalogram. Multimodality monitoring enables immediate detection and prevention of acute neurologic injury as well as appropriate intervention based on patients' individual disease states in the neurocritical care unit. Real-time analysis of cerebral physiologic, metabolic, and cardiovascular parameters simultaneously has broadened knowledge about complex brain pathophysiology and cerebral hemodynamics. Integration of this information allows for more precise diagnosis and optimization of management of patients with brain injury.
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Affiliation(s)
- Katja Elfriede Wartenberg
- Neurological Intensive Care Unit, New York Presbyterian Hospital, Columbia University Medical Center, 710 W. 168th Street, New York, NY 10032, USA
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