Near-infrared oximetry of the brain

Singlet, Doublet, and Triplet Emissions of Diarylamine-Modified Bismuth Pincer Complexes

We present six bismuth complexes (NCRN)BiX2 (X = Cl, I) with diarylamine-modified pincer ligands (NCRN = (4-R-C6H4)2N-C6H2-(CH2NMe2)2-1,3; R = Me, O, NMe2) and report on their optoelectronic, photophysical, and electrochemical properties. The complexes exhibit intriguing photophysical behavior, with the p-tolyl and p-anisyl derivatives showing phosphorescence at 77 K in frozen solvent matrices and at room temperature (r.t.) in the solid state. In THF solutions at r.t., only ligand-based fluorescence is observed with strongly reduced quantum yields compared to free proligands NCHRN. Electrochemical studies reveal up to three reversible one-electron oxidations. The NMe2-substituted complexes display the lowest oxidation potentials and the largest number of redox waves. Radical cations [NCHNMe2N]+ and [(NCNMe2N)BiX2]+ are chemically stable and fluoresce weakly in the near-infrared (NIR) at ca. 1200 nm.

Effect of Positional Changes on Cerebral Perfusion in Parkinson's Disease Patients With Orthostatic Hypotension

OBJECTIVE

Orthostatic hypotension (OH) is one of the most common autonomic dysfunctions in Parkinson's disease (PD) patients. However, many patients with OH are asymptomatic. Conversely, orthostatic dizziness (OD) is not always associated with OH. We investigated the effects of positional changes on cerebral perfusion in patients with PD and OH.

METHODS

We enrolled 42 patients, comprising 31 PD patients and 11 healthy controls. All the subjects underwent the following clinical assessments: the OH questionnaire, head-up tilt test (HUTT) with transcranial Doppler (TCD), near-infrared spectroscopy, measurement of the change in oxygenated hemoglobin (ΔHboxy) during the squat-to-stand test (SST), measurement of the time derivative of total hemoglobin (DHbtot), and time taken to reach the peak (peak time [PT]) of DHbtot after restanding.

RESULTS

The mean flow velocity change (ΔMFV) in the TCD during the HUTT failed to differentiate between the PD-OH(+) and PD-OH(-) groups. The change in oxygenated hemoglobin ΔHboxy was greater in the PD-OH(+) group, which persisted for 9 min until the end of the HUTT only in the left hemisphere. During SST, PT was significantly delayed in the left hemisphere in PD-OH(+) patients.

CONCLUSION

Although TCD demonstrated no significant difference in ΔMFV, the parameters measured by near-infrared spectroscopy, such as ΔHboxy during HUTT and PT during the SST, significantly increased ΔHboxy or delayed PT in the left hemisphere of PD-OH(+). Positional changes have a detrimental effect on cerebral hemodynamics in patients with PD and OH, especially in the left hemisphere.

Recent Advances in MR Imaging-based Quantification of Brain Oxygen Metabolism

The metabolic rate of oxygen (MRO2) is fundamental to tissue metabolism. Determination of MRO2 demands knowledge of the arterio-venous difference in hemoglobin-bound oxygen concentration, typically expressed as oxygen extraction fraction (OEF), and blood flow rate (BFR). MRI is uniquely suited for measurement of both these quantities, yielding MRO2 in absolute physiologic units of µmol O2 min-1/100 g tissue. Two approaches are discussed, both relying on hemoglobin magnetism. Emphasis will be on cerebral oxygen metabolism expressed in terms of the cerebral MRO2 (CMRO2), but translation of the relevant technologies to other organs, including kidney and placenta will be touched upon as well. The first class of methods exploits the blood's bulk magnetic susceptibility, which can be derived from field maps. The second is based on measurement of blood water T2, which is modulated by diffusion and exchange in the local-induced fields within and surrounding erythrocytes. Some whole-organ methods achieve temporal resolution adequate to permit time-series studies of brain energetics, for instance, during sleep in the scanner with concurrent electroencephalogram (EEG) sleep stage monitoring. Conversely, trading temporal for spatial resolution has led to techniques for spatially resolved approaches based on quantitative blood oxygen level dependent (BOLD) or calibrated BOLD models, allowing regional assessment of vascular-metabolic parameters, both also exploiting deoxyhemoglobin paramagnetism like their whole-organ counterparts.

Transmission of slow waves in Masimo O3 near infrared spectroscopy measures

Introduction

Cerebral autoregulation (CA) dysfunction is a key complication following brain injury. CA assessment using near-infrared spectroscopy (NIRS) offers a promising alternative to the current non-invasive standard, cerebral blood flow velocity (CBFV) measured with transcranial Doppler.

Research question

Can autoregulatory slow waves (frequency range 0.005-0.05 Hz) associated with spontaneous and induced changes in ABP in healthy volunteers be detected by parameters measured with the Masimo O3 NIRS device?

Methods

ABP, CBFV and Masimo O3 parameters were measured in 10 healthy volunteers at baseline and during ABP oscillations induced by squat/stand manoeuvres. Transmission of slow waves was assessed with power spectral density and coherence analysis in NIRS signals and compared to that of CBFV.

Results

At baseline, slow waves were detected with sufficient power that substantially exceeded the signals' measurement resolution in all parameters except cerebral oxygen saturation. During ABP oscillations in the 0.033 Hz range (induced by squat/stand), the power of slow waves increased in all parameters in a similar pattern, with total (cHb) and oxygenated (O2Hb) haemoglobin concentrations most closely mirroring CBFV (median standardised power [first-third quartile], baseline vs squat/stand: CBFV 0.35 [0.28-0.42] vs 0.50 [0.45-0.62], O2Hb 0.47 [0.33-0.68] vs 0.61 [0.59-0.69]). Coherence with ABP increased for both CBFV and NIRS measures from low at baseline (<0.4) to high during induced changes (>0.8).

Conclusion

Spontaneous fluctuations in ABP can be observed in analysed Masimo O3 metrics to a varying degree. The clinical utility of Masimo O3 signals in CA assessment requires further investigation in brain injury patients.

Cerebral oxygenation and perfusion kinetics monitoring of military aircrew at high G using novel fNIRS wearable system

Introduction

Real-time physiological episode (PE) detection and management in aircrew operating high-performance aircraft (HPA) is crucial for the US Military. This paper addresses the unique challenges posed by high acceleration (G-force) in HPA aircrew and explores the potential of a novel wearable functional near-infrared spectroscopy (fNIRS) system, named NIRSense Aerie, to continuously monitor cerebral oxygenation during high G-force exposure.

Methods

The NIRSense Aerie system is a flight-optimized, wearable fNIRS device designed to monitor tissue oxygenation 13-20 mm below the skin's surface. The system includes an optical frontend adhered to the forehead, an electronics module behind the earcup of aircrew helmets, and a custom adhesive for secure attachment. The fNIRS optical layout incorporates near-distance, middle-distance, and far-distance infrared emitters, a photodetector, and an accelerometer for motion measurements. Data processing involves the modified Beer-Lambert law for computing relative chromophore concentration changes. A human evaluation of the NIRSense Aerie was conducted on six subjects exposed to G-forces up to +9 Gz in an Aerospace Environmental Protection Laboratory centrifuge. fNIRS data, pulse oximetry, and electrocardiography (HR) were collected to analyze cerebral and superficial tissue oxygenation kinetics during G-loading and recovery.

Results

The NIRSense Aerie successfully captured cerebral deoxygenation responses during high G-force exposure, demonstrating its potential for continuous monitoring in challenging operational environments. Pulse oximetry was compromised during G-loading, emphasizing the system's advantage in uninterrupted cerebrovascular monitoring. Significant changes in oxygenation metrics were observed across G-loading levels, with distinct responses in Deoxy-Hb and Oxy-Hb concentrations. HR increased during G-loading, reflecting physiological stress and the anti-G straining maneuver.

Discussion

The NIRSense Aerie shows promise for real-time monitoring of aircrew physiological responses during high G-force exposure. Despite challenges, the system provides valuable insights into cerebral oxygenation kinetics. Future developments aim for miniaturization and optimization for enhanced aircrew comfort and wearability. This technology has potential for improving anti-G straining maneuver learning and retention through real-time cerebral oxygenation feedback during centrifuge training.

Differences in time-frequency characteristics between healthy controls and TBI patients during hypercapnia assessed via fNIRS

Damage to the cerebrovascular network is a universal feature of traumatic brain injury (TBI). This damage is present during different phases of the injury and can be non-invasively assessed using functional near infrared spectroscopy (fNIRS). fNIRS signals are influenced by partial arterial carbon dioxide (PaCO2), neurogenic, Mayer waves, respiratory and cardiac oscillations, whose characteristics vary in time and frequency and may differ in the presence of TBI. Therefore, this study aims to investigate differences in time-frequency characteristics of these fNIRS signal components between healthy controls and TBI patients and characterize the changes in their characteristics across phases of the injury. Data from 11 healthy controls and 21 TBI patients were collected during the hypercapnic protocol. Results demonstrated significant differences in low-frequency oscillations between healthy controls and TBI patients, with the largest differences observed in Mayer wave band (0.06 to 0.15 Hz), followed by the PaCO2 band (0.012 to 0.02 Hz). The effects within these bands were opposite, with (i) Mayer wave activity being lower in TBI patients during acute phase of the injury (d = 0.37 [0.16, 0.57]) and decreasing further during subacute (d = 0.66 [0.44, 0.87]) and postacute (d = 0.75 [0.50, 0.99]) phases; (ii) PaCO2 activity being lower in TBI patients only during acute phase of the injury (d = 0.36 [0.15, 0.56]) and stabilizing to healthy levels by the subacute phase. These findings demonstrate that TBI patients have impairments in low frequency oscillations related to different mechanisms and that these impairments evolve differently over the course of injury.

Candidate neuroinflammatory markers of cerebral autoregulation dysfunction in human acute brain injury

The loss of cerebral autoregulation (CA) is a common and detrimental secondary injury mechanism following acute brain injury and has been associated with worse morbidity and mortality. However patient outcomes have not as yet been conclusively proven to have improved as a result of CA-directed therapy. While CA monitoring has been used to modify CPP targets, this approach cannot work if the impairment of CA is not simply related to CPP but involves other underlying mechanisms and triggers, which at present are largely unknown. Neuroinflammation, particularly inflammation affecting the cerebral vasculature, is an important cascade that occurs following acute injury. We hypothesise that disturbances to the cerebral vasculature can affect the regulation of CBF, and hence the vascular inflammatory pathways could be a putative mechanism that causes CA dysfunction. This review provides a brief overview of CA, and its impairment following brain injury. We discuss candidate vascular and endothelial markers and what is known about their link to disturbance of the CBF and autoregulation. We focus on human traumatic brain injury (TBI) and subarachnoid haemorrhage (SAH), with supporting evidence from animal work and applicability to wider neurologic diseases.

Effects of apolipoprotein E polymorphism on cerebral oxygen saturation, cerebral perfusion, and early prognosis after traumatic brain injury

OBJECTIVE

To investigate the effects of the apolipoprotein E (APOE) gene on oxygen saturation and cerebral perfusion in the early stages of traumatic brain injury (TBI).

METHODS

This study included 136 consecutive TBI patients and 51 healthy individuals. The APOE genotypes of all subjects were determined using quantitative fluorescence polymerase chain reaction (QF-PCR). Regional cerebral oxygen saturation (rScO2) of patients with TBI and normal subjects was monitored using near-infrared spectroscopy (NIRS). Computed tomography (CT) perfusion was used to obtain cerebral perfusion in patients with TBI and normal subjects.

RESULTS

In the TBI group, the rScO2 of APOEε4 carriers (53.06 ± 6.87%) was significantly lower than that of non-carriers (58.19 ± 5.83%, p < 0.05). Meanwhile, the MTT of APOEε4 carriers (6.75 ± 1.30 s) was significantly longer than that of non-carriers (5.87 ± 1.00 s, p < 0.05). Furthermore, correlation analysis showed a negative correlation between rSCO2 and MTT in patients with TBI. Both the univariate and multifactorial logistic regression analyses revealed that APOE ε4, hypoxia, MTT >5.75 s, Marshall CT Class, and GCS were independent risk factors for early poor prognosis in patients with TBI.

CONCLUSION

Both cerebral perfusion and cerebral oxygen were significantly impaired after TBI, and low cerebral perfusion and hypoxia were related to poor prognosis of patients with TBI. Compared with APOE ε4 non-carriers, APOE ε4 carriers not only had poorer cerebral perfusion and cerebral oxygen metabolism but also worse prognosis in the early stages of TBI. Furthermore, a negative correlation was observed between the rSCO2 and MTT levels. In addition, both CT perfusion scanning (CTP) and NIRS are reliable for monitoring the condition of patients with TBI in the neurological intensive care unit (NICU).

Performance estimation of optical skin probe in short wavelength infrared spectroscopy based on Monte-Carlo simulation

Optical throughput and optical path length are key parameters to obtain high signal to noise ratio and sensor sensitivity for the detection of skin tissue components based on short wavelength infrared (SWIR) spectroscopy. These parameters should be taken into account at the stage of optical system design. We aim to develop a method to estimate the optical efficiency and the effective water path length of a newly designed SWIR spectroscopy skin measurement system using Monte-Carlo photon migration simulation. To estimate the optical efficiency and the effective water path length, we investigated the characteristics of Monte-Carlo photon migration simulation utilizing one layered simple skin model. Simulation of photon transport in skin was conducted for transmission, transflection, and reflection optical configurations in both first overtone (1540 ~ 1820 nm) and combination (2040 ~ 2380 nm) wavelength ranges. Experimental measurement of skin spectrum was done using Fourier transform infrared spectroscopy based system to validate the estimation performance. Overall, the simulated results for optical efficiency and effective water path length are in good agreements with the experimental measurements, which shows the suggested method can be used as a means for the performance estimation and the design optimization of various in-vivo SWIR spectroscopic system.

Cerebral Tissue Oxygen Saturation Is Enhanced in Patients following Transcatheter Aortic Valve Implantation: A Retrospective Study

Transcatheter aortic valve implantation (TAVI) has emerged as an alternative to surgical aortic valve replacement. The aim of this study was to evaluate whether a relevant alteration in cerebral tissue oxygen saturation (rSO2) could be detected following TAVI. Retrospective data analysis included 275 patients undergoing TAVI between October 2016 and December 2020. Overall, rSO2 significantly increased following TAVI (64.6 ± 10% vs. 68.1 ± 10%, p < 0.01). However, a significant rise was only observed in patients with a preoperative rSO2 < 60%. Of the hemodynamic confounders studied, hemoglobin, mean arterial pressure and blood pH were lowered, while central venous pressure and arterial partial pressure of carbon dioxide (PaCO2) were slightly elevated (PaCO2: 39 (36−43) mmHg vs. 42 (37−47) mmHg, p = 0.03; pH: 7.41 (7.3−7.4) vs. 7.36 (7.3−7.4), p < 0.01). Multivariate linear regression modeling identified only hemoglobin as a predictor of altered rSO2. Patients with a EuroScore II above 4% and an extended ICU stay were found to have lower rSO2, while no difference was observed in patients with postoperative delirium or between the implanted valve types. Further prospective studies that eliminate differences in potential confounding variables are necessary to confirm the rise in rSO2. Future research should provide more information on the value of cerebral oximetry for identifying high-risk patients who will require further clinical interventions in the setting of the TAVI procedure.

Brain oxygenation during multiple sets of isometric and dynamic resistance exercise of equivalent workloads: Association with systemic haemodynamics

Brain function relies on sufficient blood flow and oxygen supply. Changes in cerebral oxygenation during exercise have been linked to brain activity and central command. Isometric- and dynamic-resistance exercise-(RE) may elicit differential responses in systemic circulation, neural function and metabolism; all important regulators of cerebral circulation. We examined whether (i) cerebral oxygenation differs between isometric- and dynamic-RE of similar exercise characteristics and (ii) cerebral oxygenation changes relate to cardiovascular adjustments occurring during RE. Fourteen men performed, randomly, an isometric-RE and a dynamic-RE of similar characteristics (bilateral-leg-press, 2-min×4-sets, 30% of maximal-voluntary-contraction, equivalent tension-time-index/workload). Cerebral-oxygenation (oxyhaemoglobin-O₂Hb; total haemoglobin-tHb/blood-volume-index; deoxyhemoglobin-HHb) was assessed by NIRS and beat-by-beat haemodynamics via photoplethysmography. Cerebral-O₂Hb and tHb progressively increased from the 1st to 4th set in both RE-protocols (p < 0.05); HHb slightly decreased (p < 0.05). Changes in NIRS-parameters were similar between RE-protocols within each exercise-set (p = 0.91-1.00) and during the entire protocol (including resting-phases) (p = 0.48-0.63). O₂Hb and tHb changes were not correlated with changes in systemic haemodynamics. In conclusion, cerebral oxygenation/blood-volume steadily increased during multiple-set RE-protocols. Isometric- and dynamic-RE of matched exercise characteristics resulted in similar prefrontal oxygenation/blood volume changes, suggesting similar cerebral haemodynamic and possibly neuronal responses to maintain a predetermined force.

Exercise intensity-specific changes to cerebral blood velocity do not modulate a postexercise executive function benefit

Executive function is transiently improved (i.e., <60-min) following a single bout of aerobic exercise. A candidate mechanism for this improvement is an exercise-mediated increase in cerebral blood flow (CBF). Further, it has been proposed that an increase in CBF across the continuum of increasing exercise intensities improves the magnitude of a postexercise executive function benefit (i.e., drive theory); however, this proposal has not been empirically tested. Here, participants completed four experimental sessions: a V̇O_2peak test to determine cardiorespiratory fitness and estimated lactate threshold (LT), followed by separate 10-min sessions of light- (i.e., 25 W), moderate- (i.e., 80% estimated LT), and heavy-intensity (i.e., 15% of the difference between LT and V̇O_2peak) aerobic exercise. An estimate of CBF during exercise was achieved via transcranial Doppler ultrasound and near-infrared spectroscopy to quantify blood velocity (BV) through the middle cerebral artery and deoxygenated hemoglobin (HHb), respectively. Executive function was assessed before and after each session via the executive-mediated antisaccade task (i.e., saccade mirror-symmetrical to a target). Results demonstrated that BV increased in relation to increasing exercise intensity, whereas HHb decreased by a comparable magnitude independent of intensity. In terms of executive function, null hypothesis and equivalence tests indicated a comparable magnitude postexercise reduction in antisaccade reaction time across exercise intensities. Accordingly, the magnitude of CBF change during exercise does not impact the magnitude of a postexercise executive function benefit.

Modifications in Near Infrared Spectroscopy for Cerebral Monitoring During Carotid Endarterectomy in Asymptomatic and Symptomatic Patients

BACKGROUND

To evaluate trends and differences in Near Infrared Spectroscopy (NIRS) monitoring during carotid endarterectomy (CEA) in patients affected by asymptomatic and symptomatic carotid artery stenosis, to predict postoperative neurological complications (PNCs).

METHODS

NIRS data of CEAs performed in a University Hospital were retrospectively reviewed. All the interventions were performed under general anesthesia and patients with intraoperative complications were excluded. Mean regional Oxygen Saturation Index (rSO₂), pre-clamp values (mean baseline value, MBv and Single Mark Baseline value, SMBv) were collected and compared to the lowest rSO₂ values during carotid cross-clamp (LSO₂v) calculated within 3 min (percentage drop, PD). ROC curve analysis with Youden's Test was performed to determine the best threshold value of PD, in order to identify PNCs in both asymptomatic and symptomatic groups.

RESULTS

Between 2007 and 2015, a total of 399 CEAs were consecutively performed with NIRS monitoring. Three-hundred-seventy-two CEAs in 355 patients were reviewed. Asymptomatic stenoses were 291 (81.9%), eleven (2.9%) PNC were registered (5 in asymptomatic and 6 in symptomatic group). Asymptomatic and symptomatic diseases had different MBv (69.5 ± 7.5 vs. 71.8 ± 6.9, respectively; P = 0.011) and similar rSO₂ value during carotid clamping (63.7 ± 8.0 vs. 63.7 ± 6.7, respectively: P = 0.958). Asymptomatic patients experiencing PNCs had a greater PD than non-PNCs group (20.5 ± 10.2% vs. 12.5 ± 7.6%, respectively using MBv as baseline value; P = 0.002), in contrast, in symptomatic patients, in which a low PD was associated with PNCs, it does not reach statistical significance (using MBv, 12.6 ± 5.4% vs. 14.8 ± 6.7%, respectively; P= 0.476). In order to detect PNCs, ROC analysis revealed an optimal PD cut-off value of -17% in asymptomatic CEAs. (Sensibility (Se) 0.80, Specificity (Sp) 0.76, PPV 0.05, NPV 0.99, Youden's index 0.56; P = 0.020) In symptomatic a threshold value of -9% was found, without reaching statistical significance.

CONCLUSIONS

NIRS as cerebral monitoring during CEA can predict PNCs in asymptomatic stenosis. Asymptomatic and symptomatic groups differ in baseline and intraprocedural cut-off values to detect an augmented PNCs risk.

Turmeric root extract supplementation improves pre-frontal cortex oxygenation and blood volume in older males and females: a randomised cross-over, placebo-controlled study

Ageing is associated with endothelial dysfunction and reduced cerebral blood flow and oxygenation. The present study aimed to investigate whether turmeric supplementation could improve cerebral oxygenation and blood volume during brain activation via dynamic handgrip exercise in older males and females. Twelve older males and females were studied using a double-blind, placebo-controlled, cross-over design. Participants ingested turmeric root extract or placebo. Heart rate and blood pressure were measured before and 2 hours after supplementation. Afterward, the exercise protocol was started, and cerebral oxygenation and blood volume were evaluated. During exercise, changes in cerebral oxygenation were higher after turmeric extract supplementation, as was blood volume compared to placebo. Changes in heart rate, systolic blood pressure, and diastolic blood pressure were not significant. The current findings indicate the potential for curcumin as an intervention for improving cerebral oxygenation and blood volume changes in older males and females. Clinical trial registry: NCT04119752.

Renal Oxygenation Measured by Near-Infrared Spectroscopy in Neonates

BACKGROUND

Acute kidney injury (AKI) affects approximately 30% of infants admitted to the neonatal intensive care unit (NICU), and increases mortality risk by 50%. Current diagnostic criteria (serum creatinine rise with oliguria) cannot detect early-onset AKI, as up to 50% of nephron damage may occur by the time these abnormalities present. Once AKI is established, clinical management is often ineffective; therefore, prevention is key. Near-infrared spectroscopy (NIRS) offers a feasible, noninvasive approach to continuously monitor renal oxygenation trends over time, serving as a surrogate marker for renal perfusion.

PURPOSE

To provide an overview of NIRS principles for measuring renal oxygenation, and to describe current evidence of how this technology is being used among infants admitted to the NICU relative to the prediction and identification of AKI.

METHODS

A comprehensive search of PubMed and CINHAL focused on renal NIRS studies in NICU preterm and term infants was conducted.

RESULTS

Findings from 34 studies were included. In term infants, reduced renal oxygenation correlated to invasive SvO2 monitoring, predicted survivability and AKI. In preterm infants, reduced renal oxygenation was associated with AKI in one study, yet contrasting findings were reported in those with patent ductus arteriosus, including those who received prostaglandin inhibitors. Normative data in all infants were sparse.

IMPLICATIONS FOR PRACTICE

Renal NIRS may offer a noninvasive measurement of kidney hypoperfusion that may precede conventional diagnostic measures.

IMPLICATIONS FOR RESEARCH

Normative data are lacking, the threshold for renal ischemia is not defined, and consensus guiding clinical treatment based on NIRS data is nonexistent.

Usefulness of Cerebral Oximetry in TBI by NIRS

Measurement of cerebral oximetry by near-infrared spectroscopy provides continuous and non-invasive information about the oxygen saturation of haemoglobin in the central nervous system. This is especially important in the case of patients with traumatic brain injuries. Monitoring of cerebral oximetry in these patients could allow for the diagnosis of inadequate cerebral oxygenation caused by disturbances in cerebral blood flow. It could enable identification of episodes of hypoxia and cerebral ischemia. Continuous bedside measurement could facilitate the rapid diagnosis of intracranial bleeding or cerebrovascular autoregulation disorders and accelerate the implementation of treatment. However, it should be remembered that the method of monitoring cerebral oximetry by means of near-infrared spectroscopy also has its numerous limitations, resulting mainly from its physical properties. This paper summarizes the usefulness of monitoring cerebral oximetry by near-infrared spectroscopy in patients with traumatic brain injury, taking into account the advantages and the disadvantages of this technique.

Peaks and valleys: oscillatory cerebral blood flow at high altitude protects cerebral tissue oxygenation

Introduction.Oscillatory patterns in arterial pressure and blood flow (at ∼0.1 Hz) may protect tissue oxygenation during conditions of reduced cerebral perfusion and/or hypoxia. We hypothesized that inducing oscillations in arterial pressure and cerebral blood flow at 0.1 Hz would protect cerebral blood flow and cerebral tissue oxygen saturation during exposure to a combination of simulated hemorrhage and sustained hypobaric hypoxia.Methods.Eight healthy human subjects (4 male, 4 female; 30.1 ± 7.6 year) participated in two experiments at high altitude (White Mountain, California, USA; altitude, 3800 m) following rapid ascent and 5-7 d of acclimatization: (1) static lower body negative pressure (LBNP, control condition) was used to induce central hypovolemia by reducing chamber pressure to -60 mmHg for 10 min(0 Hz), and; (2) oscillatory LBNP where chamber pressure was reduced to -60 mmHg, then oscillated every 5 s between -30 mmHg and -90 mmHg for 10 min(0.1 Hz). Measurements included arterial pressure, internal carotid artery (ICA) blood flow, middle cerebral artery velocity (MCAv), and cerebral tissue oxygen saturation (ScO2).Results.Forced 0.1 Hz oscillations in mean arterial pressure and mean MCAv were accompanied by a protection of ScO2(0.1 Hz: -0.67% ± 1.0%; 0 Hz: -4.07% ± 2.0%;P = 0.01). However, the 0.1 Hz profile did not protect against reductions in ICA blood flow (0.1 Hz: -32.5% ± 4.5%; 0 Hz: -19.9% ± 8.9%;P = 0.24) or mean MCAv (0.1 Hz: -18.5% ± 3.4%; 0 Hz: -15.3% ± 5.4%;P = 0.16).Conclusions.Induced oscillatory arterial pressure and cerebral blood flow led to protection of ScO2during combined simulated hemorrhage and sustained hypoxia. This protection was not associated with the preservation of cerebral blood flow suggesting preservation of ScO2may be due to mechanisms occurring within the microvasculature.

A randomized placebo-control trial of the acute effects of oxygen supplementation on exercise hemodynamics, autonomic modulation, and brain oxygenation in patients with pulmonary hypertension

BACKGROUND

The integrative physiological effects of O₂ treatment on patients with pulmonary hypertension (PH) during exercise, have not been fully investigated. We simultaneously evaluated, for the first time, the effect of oxygen supplementation on hemodynamic responses, autonomic modulation, tissue oxygenation, and exercise performance in patients with pulmonary arterial hypertension (PAH)/Chronic Thromboembolic PH(CTEPH).

MATERIAL-METHODS

In this randomized, cross-over, placebo-controlled trial, stable outpatients with PAH/CTEPH underwent maximal cardiopulmonary exercise testing, followed by two submaximal trials, during which they received supplementary oxygen (O₂) or medical-air. Continuous, non-invasive hemodynamics were monitored via photophlythesmography. Cerebral and quadriceps muscle oxygenation were recorded via near-infrared spectroscopy. Autonomic function was assessed by heart rate variability; root mean square of successive differences (RMSSD) and standard-deviation-Poincare-plot (SD1) were used as indices of parasympathetic output. Baroreceptor sensitivity (BRS) was assessed throughout the protocols.

RESULTS

Nine patients (51.4 ± 9.4 years) were included. With O₂-supplementation patients exercised for longer (p = 0.01), maintained higher cerebral oxygenated hemoglobin (O₂Hb;p = 0.02) levels, exhibited an amelioration in cortical deoxygenation (HHb;p = 0.02), and had higher average cardiac output (CO) during exercise (p < 0.05), compared to medical air; with no differences in muscle oxygenation. With O₂-supplementation patients exhibited higher BRS and sample-entropy throughout the protocol (p < 0.05) vs. medical air, and improved the blunted RMSSD, SD1 responses during exercise (p = 0.024).

CONCLUSION

We show that O₂ administration improves BRS and autonomic function during submaximal exercise in PAH/CTEPH, without significantly affecting muscle oxygenation. The improved autonomic function, along with enhancements in cardiovascular function and cerebral oxygenation, probably contributes to increased exercise tolerance with O₂-supplementation in PH patients.

The effect of muscle blood flow restriction on hemodynamics, cerebral oxygenation and activation at rest

This study tested the hypothesis that muscle blood flow restriction reduces muscle and cerebral oxygenation, at rest. In 26 healthy males, aged 33±2 yrs, physiological variables were continuously recorded during a 10-min period in two experimental conditions: a) with muscle blood flow restriction through thigh cuffs application inflated at 120 mmHg (With Cuffs, WC) and b) without restriction (No Cuffs, NC). Muscle and cerebral oxygenation were reduced by muscle blood flow restriction as suggested by the increase in both muscle and cerebral deoxygenated hemoglobin (Δ[HHb]; p<0.01) and the decrease of muscle and cerebral oxygenation index (Δ[HbDiff]; p<0.01). Hemodynamic responses were not affected by such muscle blood flow restriction, whereas baroreflex sensitivity was reduced (p=0.009). The perception of leg discomfort was higher (p<0.001) in the WC than in the NC condition. This study suggests that thigh cuffs application inflated at 120 mmHg is an effective method to reduce muscle oxygenation at rest. These changes at the muscular level seem to be sensed by the central nervous system, evoking alterations in cerebral oxygenation and baroreflex sensitivity. Novelty bullets: • Thigh cuffs application inflated at 120 mmHg effectively reduces muscle oxygenation at rest. • Limiting muscle oxygenation appears to reduce cerebral oxygenation, and baroreflex sensitivity, at rest. • Even in healthy subjects, limiting muscle oxygenation, at rest, affects neural integration.

Evaluation of the relationship between NIRS (near-infrared spectroscopy) and optic nerve sheath diameter measurement in children with increased intracranial pressure: a pilot study

Background

The increased intracranial pressure (ICP) syndrome may emerge depending on many different neurological factors and the early diagnosis and treatment are important for the prevention of neurologic damage and related mortality. In recent years, the follow-up of increased ICP with non-invasive methods has been rising. In this study, our objective was to determine the significance and any possible correlation between Optic Nerve Sheath Diameter (ONSD) and Near Infrared Spectroscopy (NIRS) in children with increased ICP.

Methods

Patients who were hospitalized in our pediatric ICU at Çukurova University Medical Faculty between June 2018 and June 2019 due to the suspicion of increased ICP were included in this study. The demographic characteristics of patients, diagnosis at admission, results of the cranial CT and MRI examinations, and results of the simultaneous ONSD and NIRS measurements were recorded.

Results

A total of 36 patients were included in our study. With respect to the diagnosis, non-traumatic causes were at the forefront in 30 patients (83.3%), and the most common causes were meningoencephalitis (n = 9; 25%) and non-traumatic bleeding (n = 7; 19.4%). Six of the patients were under the age of one year (16.7%), and the mean values of ONSD and NIRS were 4.8 ± 0.7 mm and 71.1 ± 12.4% respectively in this group. Fourteen patients were in the one to ten year age group and the mean values of ONSD and NIRS were 6.1 ± 0.6 mm and 72.7 ± 9.3% respectively. Sixteen patients were over ten years of age (44.4%), and the mean values of ONSD and NIRS were 5.6 ± 0.7 mm and 74.2 ± 16% respectively. There was no correlation between the ONSD and NIRS values (r:0.307; p = 0.068).

Conclusion

Our study showed that ONSD measurements were helpful in children with increased ICP and reflected the increase in ICP. However, our study also demonstrated that ONSD was not in correlation with the NIRS monitoring. We believe that there is a need for further studies focused on the use of ONSD and NIRS in the monitoring of increased ICP.

Hypoxia and hypercapnia effects on cerebral oxygen saturation in avalanche burial: A pilot human experimental study

BACKGROUND

A sufficient supply of oxygen is crucial to avoid hypoxic cardiac arrest and brain damage within 30 min in completely-buried avalanche victims. Snow density influences levels of hypoxia and hypercapnia. The goal of this study was to investigate the effects of hypoxia and hypercapnia on cerebral oxygenation (ScO₂) in humans breathing into an artificial air pocket.

METHODS

Each subject breathed into a closed system (air-tight face mask - plastic tube - snow air-pocket of 4 L) up to 30 min. Each subject performed three tests in different snow densities. ScO₂ was measured by a near-infrared spectroscopy (NIRS) device. Measurements included peripheral oxygen saturation (SpO₂), end-tidal carbon dioxide (ETCO₂), air pocket gases and blood gases. Snow density was assessed via standard methods and micro-computed tomography. Based on predetermined criteria, tests were classified based on whether they were terminated before 30 min and the reason for termination. The categories were: completed tests (30 min), tests terminated before 30 min when SpO₂ dropped to ≤75% and tests that were terminated before 30 min by requests of the subjects. General linear models were used to compare termination groups for changes in ScO₂, ETCO₂, SpO₂ and air pocket gases, and a multivariate analysis was used to detect factor independent effects on ScO₂.

RESULTS

ScO₂ was decreased in the group in which the tests were terminated for SpO₂ ≤ 75% caused by a decrease in oxygen supply in high snow densities. In the completed tests, an increase in ScO₂ occurred despite decreased oxygen supply and decreased carbon dioxide removal.

CONCLUSIONS

Our data show that ScO₂ determined by NIRS was not always impaired in humans breathing into an artificial air pocket despite decreased oxygen supply and decreased carbon dioxide removal. This may indicate that in medium to low snow densities brain oxygenation can be sufficient, which may reflect the initial stage of the triple H (hypothermia, hypoxia, and hypercapnia) syndrome. In high snow densities, ScO₂ showed a significant decrease caused by a critical decrease in oxygen supply. This could lead to a higher risk of hypoxic cardiac arrest and brain damage.

Increased cerebral blood flow supports a single-bout postexercise benefit to executive function: evidence from hypercapnia

A single bout of aerobic exercise improves executive function; however, the mechanism for the improvement remains unclear. One proposal asserts that an exercise-mediated increase in cerebral blood flow (CBF) enhances the efficiency of executive-related cortical structures. To examine this, participants completed separate 10-min sessions of moderate- to heavy-intensity aerobic exercise, a hypercapnic environment (i.e., 5% CO₂), and a nonexercise and nonhypercapnic control condition. The hypercapnic condition was included because it produces an increase in CBF independent of metabolic demands. An estimate of CBF was achieved via transcranial Doppler ultrasound and near-infrared spectroscopy that provided measures of middle cerebral artery blood velocity (BV) and deoxygenated hemoglobin (HHb), respectively. Exercise intensity was adjusted to match participant-specific changes in BV and HHb associated with the hypercapnic condition. Executive function was assessed before and after each session via antisaccades (i.e., saccade mirror-symmetrical to a target) because the task is mediated via the same executive networks that demonstrate task-dependent modulation following single and chronic bouts of aerobic exercise. Results showed that hypercapnic and exercise conditions were associated with comparable BV and HHb changes, whereas the control condition did not produce a change in either metric. In terms of antisaccade performance, the exercise and hypercapnic, but not control, conditions demonstrated improved postcondition reaction times (RT), and the magnitude of the hypercapnic and exercise-based increase in estimated CBF was reliably related to the postcondition improvement in RT. Accordingly, results evince that an increase in CBF represents a candidate mechanism for a postexercise improvement in executive function.NEW & NOTEWORTHY Single-bout aerobic exercise "boosts" executive function, and increased cerebral blood flow (CBF) has been proposed as a mechanism for the benefit. In this study, participants completed 10 min of aerobic exercise and 10 min of inhaling a hypercapnic gas, a manipulation known to increase CBF independently of metabolic demands. Both exercise and hypercapnic conditions improved executive function for at least 20 min. Accordingly, an increase in CBF is a candidate mechanism for the postexercise improvement in executive function.

Metabolic communication during exercise

The coordination of nutrient sensing, delivery, uptake and utilization is essential for maintaining cellular, tissue and whole-body homeostasis. Such synchronization can be achieved only if metabolic information is communicated between the cells and tissues of the entire organism. During intense exercise, the metabolic demand of the body can increase approximately 100-fold. Thus, exercise is a physiological state in which intertissue communication is of paramount importance. In this Review, we discuss the physiological processes governing intertissue communication during exercise and the molecules mediating such cross-talk.

The physiology of rowing with perspective on training and health

PURPOSE

This review presents a perspective on the expansive literature on rowing.

METHODS

The PubMed database was searched for the most relevant literature, while some information was obtained from books.

RESULTS

Following the life span of former rowers paved the way to advocate exercise for health promotion. Rowing involves almost all muscles during the stroke and competition requires a large oxygen uptake, which is challenged by the pulmonary diffusion capacity and restriction in blood flow to the muscles. Unique training adaptations allow for simultaneous engagement of the legs in the relatively slow movement of the rowing stroke that, therefore, involves primarily slow-twitch muscle fibres. Like other sport activities, rowing is associated with adaptation not only of the heart, including both increased internal diameters and myocardial size, but also skeletal muscles with hypertrophy of especially slow-twitch muscle fibres. The high metabolic requirement of intense rowing reduces blood pH and, thereby, arterial oxygen saturation decreases as arterial oxygen tension becomes affected.

CONCLUSION

Competitive rowing challenges most systems in the body including pulmonary function and circulatory control with implication for cerebral blood flow and neuromuscular activation. Thus, the physiology of rowing is complex, but it obviously favours large individuals with arms and legs that allow the development of a long stroke. Present inquiries include the development of an appropriately large cardiac output despite the Valsalva-like manoeuvre associated with the stroke, and the remarkable ability of the brain to maintain motor control and metabolism despite marked reductions in cerebral blood flow and oxygenation.

Evaluation of cerebral oxygen perfusion during shoulder arthroplasty performed in the semi-beach chair position

BACKGROUND

The beach chair position is commonly used when performing shoulder arthroplasty. However, this position has been associated with hypotension, potentially leading to cerebral hypoperfusion, which may cause neurologic injury. In addition, shoulder arthroplasty cases are associated with longer operative times, posing a potentially greater risk of cerebral hypoperfusion. We aim to evaluate the risk of cerebral desaturation events (CDEs) during the course of total shoulder arthroplasty.

METHODS

Twenty-six patients undergoing shoulder arthroplasties were monitored for changes in cerebral perfusion. Seven specific time-points during the procedure were labeled for comparison of events: baseline, beach chair, incision, humeral broaching, glenoid reaming, glenoid component implantation, and humeral component implantation. Cerebral oxygen perfusion was measured using near-infrared spectroscopy. A CDE was described as a decrease of oxygen saturation greater than 20%.

RESULTS

Nineteeen of 25 subjects experienced a CDE. 42% of these patients experienced CDEs during semi-beach chair positioning. Patients experienced the largest oxygen saturation drop during semi-beach chair positioning. Transition from baseline to semi-beach chair was the only event to have a statistically significant decrease in cerebral perfusion (8%, P < .05). There was a statistically significant percentage change in mean oxygen saturation in the semi-beach chair interval (10%, P < .01) and the semi-beach chair to incision interval (7%, P < .01).

CONCLUSIONS

Most patients experienced an intraoperative CDE, with greatest incidence during semi-beach chair positioning. The largest decline in cerebral oxygen saturation occurred during semi-beach chair positioning. Implant implantation was not associated with decrease in cerebral oximetry.

Cerebral Oximetry in Syncope and Syndromes of Orthostatic Intolerance

Cerebral autoregulation is crucial for maintaining cerebral blood flow and perfusion. In recent years, the importance of cerebral oxygenation in syncope and orthostatic intolerance (OI) has received increased attention. Cerebral tissue oxygenation can be measured by using near-infrared spectroscopy (NIRS), which determines the ratio of oxygenated hemoglobin to total hemoglobin in cerebral tissue. NIRS is non-invasive technology using near-infrared light, which displays real-time cerebral tissue oxygenation. Normal values of cerebral tissue oxygenation in healthy subjects are 60 to 80%. Head-up tilt test (HUT) offers the opportunity to observe the haemodynamic changes precipitating syncope and is, today, the standard method for the evaluation of syncope and orthostatic intolerance syndromes. In previous studies where NIRS was applied during HUT, a significant decrease in cerebral tissue oxygenation both prior to and during loss-of-consciousness in vasovagal syncope (VVS) has been observed. Interestingly, cerebral tissue oxygenation appears to decrease even before haemodynamic changes can be observed. Apart from VVS, cerebral tissue oxygenation decreases during orthostatic provocation in patients with orthostatic hypotension (OH) and postural orthostatic tachycardia syndrome (POTS), in the latter even in the absence of hypotension. Importantly, decline of cerebral tissue oxygenation in VVS and POTS during HUT may not correlate with hemodynamic changes. In this mini review, we summarize the current knowledge of the application of cerebral oximetry in syncope and orthostatic intolerance syndromes, discuss its likely value as a clinical diagnostic tool and also emphasize its potential in the understanding of the relevant pathophysiology.

Comparison of the Effects of Desflurane and Sevoflurane on Cerebral Oxygen Saturation in Patients Undergoing Thyroidectomy: A Randomised Controlled Clinical Study

Objective

The commonly performed sitting position with head extended during thyroidectomy has been shown to cause adverse effects on cerebral regional oxygen saturation (CrSO2). Therefore, the present study aimed to investigate the effects of two well-known anaesthetic agents, desflurane and sevoflurane, on CrSO2 in patients undergoing thyroidectomy in the semi-sitting position by near-infra-red spectroscopy monitoring.

Methods

The study included 60 patients aged 18-65 years, with an American Society of Anesthesiologists (ASA) physical status classification score I-III, who underwent elective thyroidectomy in the semi-sitting position. The patients were randomly divided into two groups, depending on the anaesthetic agent administered: (1) sevoflurane group (Group S; n=30) and (2) desflurane group (Group D; n=30). After intubation, the patients were placed in a 45-degree semi-sitting position. Vital signs and the CrSO2 levels in both hemispheres were recorded both pre-induction and at the induction minute 1, post-intubation, post-positioning, every 5 minutes intraoperatively and in the case of sudden changes.

Results

No significant difference was found between the groups in terms of age, height, body weight, the ASA score, operative time and left- and right-hemisphere CrSO2 (p>0.05). Moreover, the two groups were statistically similar to each other with regard to peripheral capillary oxygen saturation, heart rate, systolic and diastolic blood pressure, mean artery pressure and end-tidal CO₂ (ETCO₂) levels.

Conclusion

Desflurane and sevoflurane had similar effects in the preservation of CrSO2 in patients undergoing thyroidectomy in the semi-sitting position.

Responses of cerebral blood velocity and tissue oxygenation to low-frequency oscillations during simulated haemorrhagic stress in humans

NEW FINDINGS

What is the central question of this study? Do low-frequency oscillations in arterial pressure and cerebral blood velocity protect cerebral blood velocity and oxygenation during central hypovolaemia? What is the main finding and its importance? Low-frequency oscillations in arterial pressure and cerebral blood velocity attenuate reductions in cerebral oxygen saturation but do not protect absolute cerebral blood velocity during central hypovolaemia. This finding indicates the potential importance of haemodynamic oscillations in maintaining cerebral oxygenation and therefore viability of tissues during challenges to cerebral blood flow and oxygen delivery.

ABSTRACT

Tolerance to both real and simulated haemorrhage varies between individuals. Exaggerated low-frequency (∼0.1 Hz) oscillations in mean arterial pressure and brain blood flow [indexed via middle cerebral artery velocity (MCAv)] have been associated with improved tolerance to reduced central blood volume. The mechanism for this association has not been explored. We hypothesized that inducing low-frequency oscillations in arterial pressure and cerebral blood velocity would attenuate reductions in cerebral blood velocity and oxygenation during simulated haemorrhage. Fourteen subjects (11 men and three women) were exposed to oscillatory (0.1 and 0.05 Hz) and non-oscillatory (0 Hz) lower-body negative pressure profiles with an average chamber pressure of -60 mmHg (randomized and counterbalanced order). Measurements included arterial pressure and stroke volume via finger photoplethysmography, MCAv via transcranial Doppler ultrasound, and cerebral oxygenation of the frontal lobe via near-infrared spectroscopy. Tolerance was higher during the two oscillatory profiles compared with the 0 Hz profile (0.05 Hz, P = 0.04; 0.1 Hz, P = 0.09), accompanied by attenuated reductions in stroke volume (P < 0.001) and cerebral oxygenation of the frontal lobe (P ≤ 0.02). No differences were observed between profiles for reductions in mean arterial pressure (P = 0.17) and MCAv (P = 0.30). In partial support of our hypothesis, cerebral oxygenation, but not cerebral blood velocity, was protected during the oscillatory profiles. Interestingly, more subjects tolerated the oscillatory profiles compared with the static 0 Hz profile, despite similar arterial pressure responses. These findings emphasize the potential importance of haemodynamic oscillations in maintaining perfusion and oxygenation of cerebral tissues during haemorrhagic stress.

Low vs high hemoglobin trigger for transfusion in vascular surgery: a randomized clinical feasibility trial

Current guidelines advocate to limit red blood cell (RBC) transfusion during surgery, but the feasibility and safety of such a strategy remain unclear, as the majority of evidence is based on postoperatively stable patients. We assessed the effects of a protocol aiming to restrict RBC transfusion throughout hospitalization for vascular surgery. Fifty-eight patients scheduled for lower limb bypass or open abdominal aortic aneurysm repair were randomly assigned, on hemoglobin drop below 9.7 g/dL, to either a low-trigger (hemoglobin &lt; 8.0 g/dL) or a high-trigger (hemoglobin &lt; 9.7 g/dL) group for RBC transfusion. Near-infrared spectroscopy assessed intraoperative oxygen desaturation in brain and muscle. Explorative outcomes included nationwide registry data on death and major vascular complications. The primary outcome, mean hemoglobin within 15 days of surgery, was significantly lower in the low-trigger group, at 9.46 vs 10.33 g/dL in the high-trigger group (mean difference, −0.87 g/dL; P = .022), as were units of RBCs transfused (median [interquartile range (IQR)], 1 [0-2] vs 3 [2-6]; P = .0015). Although the duration and magnitude of cerebral oxygen desaturation increased in the low-trigger group (median [IQR], 421 [42-888] vs 127 [11-331] minutes × %; P = .0036), muscle oxygenation was unaffected. The low-trigger group associated to a higher rate of death or major vascular complications (19/29 vs 8/29; hazard ratio, 3.20; P = .006) and fewer days alive outside the hospital within 90 days (median [IQR], 76 [67-82] vs 82 [76-84] days; P = .049). In conclusion, a perioperative protocol restricting RBC transfusion successfully separated hemoglobin levels and RBC units transfused. Exploratory outcomes suggested potential harm with the low-trigger group and warrant further trials before such a strategy is universally adopted. This trial was registered at www.clinicaltrials.gov as #NCT02465125.

Endovascular aortic repair reduces gluteal oxygenation

Background

Provoked gluteal claudication is a known risk after endovascular aortic repair (EVAR). Lowered gluteal muscle oxygenation (S_gmO₂) may be demonstrated by near-infrared spectroscopy (NIRS).

Purpose

To evaluate NIRS-determined S_gmO₂ in EVAR patients.

Material and Methods

NIRS-determined S_gmO₂ was used in an observational study design (n = 17). From the ambulatory setting, seven EVAR patients were included with reported gluteal claudication from medical records. In 10 patients scheduled for EVAR, S_gmO₂ was measured before and after the procedure. NIRS sensors were applied bilaterally on the gluteal region. Treadmill walking (12% incline, 2.4 km/h) was introduced to stress gluteal muscles.

Results

A reduced S_gmO₂ with regional side difference (P < 0.05) was noted in all 10 patients following EVAR and four reported gluteal claudication. In patients with gluteal claudication (n = 7), treadmill decreased S_gmO₂. The time to recover the S_gmO₂ was prolonged for tissue exposed to occluded hypogastric artery (median = 512 s, range = 73–1207 s vs. median = 137, range = 0–643 s; P = 0.046).

Conclusions

EVAR affects gluteal muscle oxygenation. NIRS could be used to assess whether gluteal claudication is related to lowered S_gmO₂.

Monitoring spinal cord hemodynamics and tissue oxygenation: a review of the literature with special focus on the near-infrared spectroscopy technique

STUDY DESIGN

Review.

OBJECTIVES

Clinical studies have shown that the hemodynamic management of patients following acute spinal cord injury (SCI) is an important aspect of their treatment for maintaining spinal cord (SC) perfusion and minimizing ischemic secondary injury to the SC. While this highlights the importance of ensuring adequate perfusion and oxygenation to the injured cord, a method for the real-time monitoring of these hemodynamic measures within the SC is lacking. The purpose of this review is to discuss current and potential methods for SC hemodynamic monitoring with special focus on applications using near-infrared spectroscopy (NIRS).

METHODS

A literature search using the PubMed database. All peer-reviewed articles on NIRS monitoring of SC published from inception to May 2019 were reviewed.

RESULTS

Among 125 papers related to SC hemodynamics monitoring, 26 focused on direct/indirect NIRS monitoring of the SC.

DISCUSSION

Current options for continuous, non-invasive, and real-time monitoring of SC hemodynamics are challenging and limited in scope. As a relatively new technique, NIRS has been successfully used for monitoring human cerebral hemodynamics, and has shown promising results in intraoperative assessment of SC hemodynamics in both human and animal models. Although utilizing NIRS to monitor the SC has been validated, applying NIRS clinically following SCI requires further development and investigation.

CONCLUSIONS

NIRS is a promising non-invasive technique with the potential to provide real-time monitoring of relevant parameters in the SC. Currently, in its first developmental stages, further clinical and experimental studies are mandatory to ensure the validity and safety of NIRS techniques.

Shoulder surgery in beach chair position causing perioperative stroke: Four cases and a review of the literature

Perioperative stroke is a rare, but serious complication in shoulder-arthroscopy or arthroplasty. Recent literature suggests the beach chair position, widely used during shoulder surgery, might induce severe perioperative hypotension, and with this cerebral desaturation and ultimately perioperative stroke. In this article we report four cases of perioperative stroke in shoulder surgery. In all cases, patients underwent brief periods of hypotension, which might have caused perioperative stroke. Based on an analysis in our hospital, we think the prevalence of perioperative stroke during shoulder surgery is higher than reported. Surgeons should be aware of this risk when using the beach chair position.

Monitoring of cerebral oximetry during head-up tilt test in adults with history of syncope and orthostatic intolerance

Aims

We applied near-infrared-spectroscopy (NIRS) to measure absolute frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients investigated for unexplained syncope.

Methods and results

Synchronized non-invasive beat-to-beat haemodynamic monitoring, ECG, SctO2 (NIRS; normal range: 60-80%), and peripheral oxygen saturation (left hand, SpO2) were applied during HUT in a random sample of patients with unexplained syncope. Tracings of 54 patients (mean-age: 55 ± 19 years, 39% male) with negative HUT, vasovagal syncope (VVS), or orthostatic hypotension (OH) were analysed. In 44 patients HUT was diagnostic, in 10 HUT was negative. Thirty-one experienced VVS. Of these, 6 had spontaneous and 25 nitroglycerin-induced syncope. Thirteen patients had orthostatic hypotension (OH). Although there was no significant change in mean-arterial pressure from baseline to 1 min before syncope or end of passive HUT phase (-1.4 ± 13.9 mmHg; P = 0.45), there was a significant fall in SctO2 during the same period (-3.2 ± 3.2%; P ≤ 0.001). Among patients who experienced syncope, a decrease in SctO2 from 71 ± 5% at baseline to 53 ± 9% (P < 0.001) at syncope was observed. During HUT, there was a significant difference in delta SctO2 between spontaneous VVS (-4.5 ± 3.0%) and negative HUT (-1.3 ± 1.9%; P  = 0.021), but not between spontaneous VVS and OH (-5.4 ± 4.2%; P = 0.65). In spontaneous VVS, progressive decrease of SctO2 was independent of mean arterial pressure decrease (P  = 0.22).

Conclusions

Progressive decrease in cerebral tissue oxygenation independent of mean-arterial pressure may precede spontaneous vasovagal reflex during tilt. Patients experience syncope when SctO2 falls below 60%. These data confirm clinical utility of absolute cerebral oximetry monitoring for syncope investigation. We applied NIRS to measure frontal cerebral tissue oxygen saturation (SctO2) during head-up tilt test (HUT) in patients with unexplained syncope. In 44 of 54 patients, HUT was diagnostic. In patients with syncope, a significant SctO2-decrease was observed. Different patterns of SctO2 can be detected.

The age-related reduction in cerebral blood flow affects vertebral artery more than internal carotid artery blood flow

Ageing reduces cerebral blood flow (CBF), while mean arterial pressure (MAP) becomes elevated. According to 'the selfish brain' hypothesis of hypertension, a reduction in vertebral artery blood flow (VA) leads to increased sympathetic activity and thus increases MAP. In twenty-two young (24 ± 3 years; mean ± SD) and eleven elderly (70 ± 5 years) normotensive men, duplex ultrasound evaluated whether the age-related reduction in CBF affects VA more than internal carotid artery (ICA) blood flow. Pulse-contour analysis evaluated MAP while near-infrared spectroscopy determined frontal lobe oxygenation and transcranial Doppler middle cerebral artery mean blood velocity (MCA V_mean ). During supine rest, MAP (90 ± 13 versus 78 ± 9 mmHg; P<0·001) was elevated in the older subjects while their frontal lobe oxygenation (68 ± 7% versus 77 ± 7%; P<0·001), MCA V_mean (49 ± 9 versus 60 ± 12 cm s^-1 ; P = 0·016) and CBF (754 ± 112 versus 900 ± 144 ml min^-1 ; P = 0·004) were low reflected in VA (138 ± 48 versus 219 ± 50 ml min^-1 ; P<0·001) rather than in ICA flow (616 ± 96 versus 680 ± 120 ml min^-1 ; P = 0·099). In conclusion, blood supply to the brain and its oxygenation are affected by ageing and the age-related decline in VA flow appears to be four times as large as that in ICA and could be important for the age-related increase in MAP.

Effect of leg immersion in mild warm carbonated water on skin and muscle blood flow

Leg immersion in carbonated water improves endothelial-mediated vasodilator function and decreases arterial stiffness but the mechanism underlying this effect remains poorly defined. We hypothesized that carbonated water immersion increases muscle blood flow. To test this hypothesis, 10 men (age 21 ± 0 years; mean ± SD) underwent lower leg immersion in tap or carbonated water at 38°C. We evaluated gastrocnemius muscle oxyhemoglobin concentration and tissue oxygenation index using near-infrared spectroscopy, skin blood flow by laser Doppler flowmetry, and popliteal artery (PA) blood flow by duplex ultrasound. Immersion in carbonated, but not tap water elevated PA (from 38 ± 14 to 83 ± 31 mL/min; P < 0.001) and skin blood flow (by 779 ± 312%, P < 0.001). In contrast, lower leg immersion elevated oxyhemoglobin concentration and tissue oxygenation index with no effect of carbonation (P = 0.529 and P = 0.495). In addition, the change in PA blood flow in response to immersion in carbonated water correlated with those of skin blood flow (P = 0.005) but not oxyhemoglobin concentration (P = 0.765) and tissue oxygenation index (P = 0.136) while no relations was found for tap water immersion. These findings indicate that water carbonation has minimal effect on muscle blood flow. Furthermore, PA blood flow increases in response to lower leg immersion in carbonated water likely due to a large increase in skin blood flow.

Elevated Renal Oxygen Extraction During Open Abdominal Aortic Aneurysm Repair Is Related to Postoperative Renal Dysfunction

BACKGROUND

Open abdominal aortic aneurysm repair is often followed by elevated plasma creatinine, likely due to impaired renal blood flow. We evaluated whether postoperative elevation in creatinine relates to renal oxygen extraction during surgery as an index of renal blood flow and also monitored frontal lobe oxygenation.

METHODS

For 19 patients (66 ± 10 years; mean ± SD) undergoing open infrarenal abdominal aortic aneurysm repair, renal oxygen extraction was determined by arterial and renal vein catheterization. Near-infrared spectroscopy determined frontal lobe oxygenation.

RESULTS

During surgery mean arterial pressure (from 102 ± 14 to 65 ± 11 mm Hg; P < .0001), arterial hemoglobin (from 7.7 ± 0.7 to 6.6 ± 0.8 mmol/L; P < 0.0001), and frontal lobe oxygenation (from 74 ± 6% to 70 ± 6%; P = .0414) decreased, while renal oxygen extraction increased (from 5.3% [4.3-8.1]; median [interquartile range] to 10.8% [5.8-17.5]; P = .0405). Plasma creatinine became significantly elevated on the second day after the operation (from 83 [73-101] to 105 µmol/L [79-143]; P = .0062) with a peak increase observed after 2 days (1-2). The peak increase in creatinine correlated to intraoperative renal oxygen extraction ( r = 0.51; P = .026).

CONCLUSION

Kidney function was affected after open abdominal aortic aneurysm repair likely related to limited renal blood flow. We take the increase in renal oxygen extraction and reduction in frontal lobe oxygenation to suggest that mean arterial pressure and hemoglobin were too low to maintain renal and cerebral circulation in vascular surgical patients.

The effects of multi-stage exercise with and without concurrent cognitive performance on cardiorespiratory and cerebral haemodynamic responses

INTRODUCTION

Studies of cerebral haemodynamics have shown changes with increased exercise intensity, but the patterns have been highly variable and reliable associations with cognitive performance have not been identified. The aim of this study was to examine whether exercise-induced changes in oxygenated haemoglobin (O₂Hb) led to changes in concomitant cognitive performance.

METHODS

This study examined cardiorespiratory and cerebral haemodynamics during multi-stage exercise from rest to exhaustion, with (Ex + C) and without (Ex) concurrent cognitive performance (Go/No-go task).

RESULTS

The presence of the cognitive task affected both cardiorespiratory and cerebral haemodynamics. The patterns in the cerebral haemodynamics during Ex and Ex + C diverged above the respiratory compensation threshold (RCT), but differences were significant only at 100% [Formula: see text], displaying increased deoxygenated haemoglobin (HHb), decreased difference between oxygenated and deoxygenated haemoglobin (HbDiff), and decreased cerebral oxygenation (COx) during Ex + C. More complex haemodynamic trends against intensity during Ex + C suggested that the presence of a cognitive task increases cerebral metabolic demand at high exercise intensities. The levels of O₂Hb, HHb, HbDiff and total haemoglobin increased most steeply at intensities around the RCT during both Ex and Ex + C, but these changes were not accompanied by improved cognitive performance.

CONCLUSION

The primary hypothesis, that cognitive performance would match changes in O₂Hb, was not supported. Small variations in reaction time and response accuracy across exercise intensities were not significant, suggesting that cognitive performance is unaffected by intense short-duration exercise. Our results add further evidence that exercise-induced changes in cerebral haemodynamics do not affect cognitive performance.

Accelerated vascular aging and persistent cognitive impairment in older female breast cancer survivors

Advances in breast cancer treatment have markedly increased survivorship over the past three decades, with over 3.1 million survivors expected to live into their 70s and 80s. Without symptom relief interventions, nearly 35% of these survivors will have life-altering and distressing cognitive symptoms. This pilot study explored associations between serum markers of vascular aging, laterality in cerebral oxygenation, and severity of cognitive impairment in women, 12-18 months after chemotherapy for stage 2/3 invasive ductal breast cancer. Fifteen women (52-84 years) underwent a brief cognitive assessment (Montreal Cognitive Assessment [MOCA]) and blood draws to assess markers of vascular aging (interleukin-6 [IL-6], tumor necrosis factor alpha [TNF-α], C-reactive protein [CRP], and insulin growth factor-1 [IGF-1]). All underwent a computer-based test protocol that is known to increase blood flow within the frontal lobes. Percent cerebral oxyhemoglobin saturation (rcSO₂) was recorded during and after testing. Laterality in rcSO₂ was defined by ≥ 3% difference between left and right rcSO₂ (|rcSO₂ mean_{RIGHT -} mean_LEFT|). Eight participants had MOCA scores between 21 and 25 points, suggestive of mild cognitive impairment. Neither CRP (r = -.24) nor IL-6 (r = .34) nor TNF-α (r = .002) were associated with MOCA scores. Higher IL-6 was associated with greater laterality (r = .41). MOCA scores were significantly lower in subjects with laterality in rcSO₂ than in those without laterality (F_(1,14) = 13.5, p = 003). Lower IGF-1 was significantly associated with greater laterality (r = - .66, p = .007) and lower cognitive function (r = .58). These findings suggest that persistent cognitive impairment is associated with phenotypical changes consistent with accelerated vascular aging.

Cerebral Oximetry for Detecting High-mortality Risk Patients with Cryptococcal Meningitis

Background

Cryptococcus is the commonest cause of adult meningitis in Africa, with 50%–70% experiencing increased intracranial pressure. Cerebral oximetry is a noninvasive near-infrared spectroscopy technology to monitor percent regional cerebral tissue oxygenation (rSO₂). We assessed if cerebral oximetry predicts meningitis mortality.

Methods

We performed cerebral oximetry within 14 days of cryptococcal meningitis diagnosis on 121 Ugandans from April 2016 to September 2017. We evaluated baseline rSO₂ association with mortality by multivariable logistic regression and correlation with other clinical factors. We compared groups formed by initial rSO₂ <30% vs ≥30% for longitudinal change with mixed effects models. We measured change in %rSO₂ before and after lumbar puncture (LP).

Results

The median initial rSO₂ (interquartile range) was 36% (29%–42%), and it was <30% in 29% (35/121). For 30-day mortality, the unadjusted odds ratio (per 5% increase in rSO₂) was 0.73 (95% confidence interval [CI], 0.58 to 0.91; P = .005). Those with initial rSO₂ <30% had 3.4 (95% CI, 1.5 to 8.0) higher odds of 30-day mortality than those with initial rSO₂ ≥30%. Hemoglobin correlated with initial rSO₂ (rho = .54; P < .001), but rSO₂ did not correlate with pulse oximetry, intracranial pressure, cerebral perfusion pressure, or quantitative cerebrospinal fluid culture, and rSO₂ was unchanged pre/post–lumbar punctures. The longitudinal rSO₂ measurements change was 15% (95% CI, 12% to 18%) lower in the group with initial rSO₂ <30%.

Conclusions

Individuals with cryptococcal meningitis and low cerebral oximetry (rSO₂ < 30%) have high mortality. Cerebral oximetry may be useful as a prognostic marker of mortality. Targeted interventions to improve rSO₂ should be tested in trials to try to decrease mortality in meningitis.

Effects of respiratory and applied muscle tensing interventions on responses to a simulated blood draw among individuals with high needle fear

Fear of blood and needles increases risk for presyncopal symptoms. Applied muscle tension can prevent or attenuate presyncopal symptoms; however, it is not universally effective. This study examined the effects of applied muscle tension, a respiratory intervention, and a no treatment control condition, on presyncopal symptoms and cerebral oxygenation, during a simulated blood draw with individuals highly fearful of needles. Participants (n = 95) completed questionnaires, physiological monitoring, and two trials of a simulated blood draw with recovery. Presyncopal symptoms decreased across trials; however, no group differences emerged. Applied muscle tension was associated with greater cerebral oxygenation during trial two, and greater end-tidal carbon dioxide during both trials. The respiratory intervention did not differ from the no treatment control. Applied muscle tension is an intervention that can increase cerebral oxygenation and end-tidal carbon dioxide. While the respiratory intervention is promising within therapeutic settings, it was not efficacious after a brief audio training.

The assessment of Buerger's exercise on dorsal foot skin circulation in patients with vasculopathic diabetic foot ulcer by using wireless near-infrared spectroscope: a cohort prospective study

The improvement of peripheral circulation is crucial for the care of vasculopathic diabetic foot ulcer (DFU). Near-infrared spectroscopy (NIRS) was used to investigate the effects of Buerger's exercise on dorsal foot skin circulation with novel technique of measuring the absorption difference in wavelength of light between oxy-hemoglobin (HbO₂) and deoxy-hemoglobin (HbR). Patients with vasculopathic DFU who could tolerate Buerger's exercise three times a day at home for at least 8 weeks were enrolled (group A). They were divided into two subgroups: without previous percutaneous transluminal angioplasty (PTA) (group A1) vs. with previous PTA (group A2). Wireless NIRS were applied on patients' dorsal foot to assess the peripheral circulation in follow-up clinics. The patients' wound condition, follow-up time, and concentration of HbO₂ and total hemoglobin (HbT) before and after exercise rehabilitation program were documented. From May 2015 to February 2016, 14 patients with average age of 70.2 ± 11.2 were enrolled in this study (group A), including eight without previous PTA (group A1), and six with previous PTA (group A2). The concentration of HbO2 and HbT were significantly increased after exercise rehabilitation program training in group A (p = 0.024 in HbO₂, p = 0.02 in HbT, n = 14) and group A2 (p = 0.021 in HbO₂, p = 0.028 in HbT, n = 6), while the concentration in group A1 were improved with borderline significance after exercise (p = 0.055 in HbO₂, p = 0.058 in HbT, n = 8). The majority of the ulcers were either completely healed (11/14 = 78.57%) or improving (3/14 = 21.43%). Buerger's exercise improved the peripheral circulation and wound condition in patients with vasculopathic DFU. The wireless apparatus is a novel and efficient tool to monitor rehabilitation program.

Dopamine-dependent social information processing in non-human primates

RATIONALE

Dopamine (DA) is a neurotransmitter whose roles have been suggested in various aspects of brain functions. Recent studies in rodents have reported its roles in social function. However, how DA is involved in social information processing in primates has largely remained unclear.

OBJECTIVES

We investigated prefrontal cortical (PFC) activities associated with social vs. nonsocial visual stimulus processing.

METHODS

Near-infrared spectroscopy (NIRS) was applied to Japanese macaques, along with pharmacological manipulations of DA transmission, while they were gazing at social and nonsocial visual stimuli.

RESULTS

Oxygenated (oxy-Hb) and deoxygenated (deoxy-Hb) hemoglobin changes as well as functional connectivity based on such Hb changes within the PFC network which were distinct between social and nonsocial stimuli were observed. Administration of both D1 and D2 receptor antagonists affected the Hb changes associated with social stimuli, whereas D1, but not D2, receptor antagonist affected the Hb changes associated with nonsocial stimuli.

CONCLUSIONS

These results suggest that mesocortical DA transmission in the PFC plays significant roles in social information processing, which involves both D1 and D2 receptor activation, in nonhuman primates. However, D1 and D2 receptor signaling in the PFC mediates different aspects of social vs. nonsocial information processing.

Cyclical blood flow restriction resistance exercise: a potential parallel to remote ischemic preconditioning?

Remote ischemic preconditioning (RIPC) is characterized by the cyclical application of limb blood flow restriction and reperfusion and has been shown to protect vital organs during a subsequent ischemic insult. Blood flow restriction exercise (BFRE) similarly combines bouts of blood flow restriction with low-intensity exercise and thus could potentially emulate the protection demonstrated by RIPC. One concern with BFRE, however, is the potential for an augmented rise in sympathetic outflow due to greater activation of the exercise pressor reflex. Because of the use of lower workloads, however, we hypothesized that BFRE would elicit an attenuated increase in sympathetic outflow [assessed via plasma norepinephrine (NE) and mean arterial pressure (MAP)] and middle cerebral artery velocity (MCAv) when compared with conventional exercise (CE). Fifteen subjects underwent two leg press exercise interventions: 1) BFRE-220 mmHg bilateral thigh occlusion at 20% 1 rep-max (1RM), and 2) CE-65% 1RM without occlusion. Each condition consisted of 4 × 5-min cycles of exercise, with 3 × 10-reps in each cycle. Five minutes of rest and reperfusion (for BFRE) followed each cycle. MAP increased with exercise (P < 0.001) and was 4-5 mmHg higher with CE versus BFRE (P ≤ 0.09). Mean MCAv also increased with exercise (P < 0.001) and was higher with CE compared with BFRE during the first bout of exercise only (P = 0.07). Plasma NE concentration increased with CE only (P < 0.001) and was higher than BFRE throughout exercise (P ≤ 0.02). The attenuated sympathetic response, combined with similar cerebrovascular responses, suggest that cyclical BFRE could be explored as an alternative to CE in the clinical setting.

Combining remote ischemic preconditioning and aerobic exercise: a novel adaptation of blood flow restriction exercise

Remote ischemic preconditioning (RIPC) can attenuate tissue damage sustained by ischemia-reperfusion injury. Blood flow restriction exercise (BFRE) restricts blood flow to exercising muscles. We implemented a novel approach to BFRE with cyclical bouts of blood flow restriction-reperfusion, reflecting the RIPC model. A concern about BFRE, however, is potential amplification of the exercise pressor reflex, which could be unsafe in at-risk populations. We hypothesized that cyclical BFRE would elicit greater increases in sympathetic outflow and arterial pressure than conventional exercise (CE) when performed at the same relative intensity. We also assessed the cerebrovascular responses due to potential implementation of BFRE in stroke rehabilitation. Fourteen subjects performed treadmill exercise at 65-70% maximal heart rate with and without intermittent BFR (4 × 5-min intervals of bilateral thigh-cuff pressure followed by 5-min reperfusion periods). Mean arterial pressure (MAP), plasma norepinephrine (NE), and middle and posterior cerebral artery velocities (MCAv and PCAv) were compared between trials. As expected, BFRE elicited higher concentration NE compared with CE (1249 ± 170 vs. 962 ± 114 pg/ml; P = 0.06). Unexpectedly, however, there were no differences in MAP between conditions (overall P = 0.33), and MAP was 4-5 mmHg lower with BFRE versus CE during the reperfusion periods (P ≤ 0.05 for reperfusion periods 3 and 4). There were no differences in MCAv or PCAv between trials (P ≥ 0.22), suggesting equivalent cerebrometabolic demand. The exaggerated sympathoexcitatory response with BFRE was not accompanied by higher MAP, likely because of the cyclical reperfusions. This cyclical BFRE paradigm could be adapted to cardiac or stroke rehabilitation, where exercising patients could benefit from the cardio and cerebro protection associated with RIPC.

Multichannel wearable fNIRS-EEG system for long-term clinical monitoring

Continuous brain imaging techniques can be beneficial for the monitoring of neurological pathologies (such as epilepsy or stroke) and neuroimaging protocols involving movement. Among existing ones, functional near-infrared spectroscopy (fNIRS) and electroencephalography (EEG) have the advantage of being noninvasive, nonobstructive, inexpensive, yield portable solutions, and offer complementary monitoring of electrical and local hemodynamic activities. This article presents a novel system with 128 fNIRS channels and 32 EEG channels with the potential to cover a larger fraction of the adult superficial cortex than earlier works, is integrated with 32 EEG channels, is light and battery-powered to improve portability, and can transmit data wirelessly to an interface for real-time display of electrical and hemodynamic activities. A novel fNIRS-EEG stretchable cap, two analog channels for auxiliary data (e.g., electrocardiogram), eight digital triggers for event-related protocols and an internal accelerometer for movement artifacts removal contribute to improve data acquisition quality. The system can run continuously for 24 h. Following instrumentation validation and reliability on a solid phantom, performance was evaluated on (1) 12 healthy participants during either a visual (checkerboard) task at rest or while pedalling on a stationary bicycle or a cognitive (language) task and (2) 4 patients admitted either to the epilepsy (n = 3) or stroke (n = 1) units. Data analysis confirmed expected hemodynamic variations during validation recordings and useful clinical information during in-hospital testing. To the best of our knowledge, this is the first demonstration of a wearable wireless multichannel fNIRS-EEG monitoring system in patients with neurological conditions. Hum Brain Mapp 39:7-23, 2018. © 2017 Wiley Periodicals, Inc.

The effect of the beach-chair position angle on cerebral oxygenation during shoulder surgery

BACKGROUND

Although the safety of the beach-chair position (BCP) is widely accepted, rare devastating neurologic complications have been reported and attributed to cerebral hypoperfusion. Cerebral oxygenation (regional oxygen saturation [rSO₂]) can be monitored noninvasively using near-infrared spectroscopy. The purpose of this study was to determine the effect of BCP angle on cerebral oxygenation in patients undergoing shoulder surgery in the BCP.

METHODS

Fifty patients undergoing shoulder arthroscopy were prospectively enrolled to participate. Following induction of general anesthesia, each patient's rSO₂ was recorded at 0° of elevation and again at 30°, 45°, 60°, and 80° of elevation. Mean rSO₂ values and mean differences in rSO₂ were reported.

RESULTS

An average total decrease of 5% in rSO₂ was seen when comparing 0° with 80° (P < .001). There were statistically significant differences in rSO₂ values at beach-chair angles of 0° versus 30° (P <.001), 30° versus 45° (P = .007), and 45° versus 60° (P <.001) but not between 60° and 80° (P = .12). The decrease in rSO₂ was similar between each progressive increase in the beach-chair angle, leading to a linear decline in rSO₂ as the BCP increased (regression slope of -0.060%/°, P <.001). No patient's cerebral oxygenation dropped greater than 20% from baseline. Neither body mass index nor American Society of Anesthesiologists score had a significant impact on the relation of rSO₂ to BCP angle.

CONCLUSIONS

The average drop in rSO₂ is significantly less than the threshold of 20% used as an identifier for a cerebral deoxygenation event. This study illustrates the direct effect the BCP angle has on cerebral oxygenation.