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Mathieu F, Khellaf A, Thelin EP, Zeiler FA. Continuous Thermal Diffusion-Based Cerebral Blood Flow Monitoring in Adult Traumatic Brain Injury: A Scoping Systematic Review. J Neurotrauma 2019; 36:1707-1723. [PMID: 30638125 DOI: 10.1089/neu.2018.6309] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/03/2023] Open
Abstract
Thermal diffusion flowmetry (TDF) is an appealing candidate for monitoring of cerebral blood flow (CBF) in neurocritical-care patients as it provides absolute measurements with a high temporal resolution, potentially allowing for bedside intervention that could mitigate secondary injury. We performed a systematic review of TDF-regional(r)CBF measurements and their association with (1) patient functional outcome, (2) other neurophysiological parameters, and (3) imaging-based tissue outcomes. We searched MEDLINE, EMBASE, SCOPUS, BIOSIS, GlobalHealth, and the Cochrane Databases from inception to October 2018 and relevant conference proceedings published over the last 5 years. Nine articles that explored the relationship between TDF-rCBF, mortality, and Glasgow Outcome Scale (GOS) or GOS-Extended (GOS-E) at various intervals were included. Despite being based on an overall weak body of evidence, our analysis suggests a link between sustained low or high CBF and poor functional outcome. Twenty-five studies reporting associations with neurophysiological parameters were included. The available data also point to an association between low or high TDF-rCBF and intracranial hypertension. TDF-rCBF appears to correlate well with regional brain tissue oxygenation measurements. We found no studies reporting on imaging-based tissue outcome in relation to TDF. In conclusion, despite being based on a relatively weak body of evidence, the available literature suggests a link between consistently abnormal TDF-rCBF values, intracranial hypertension, and poor functional outcome. TDF-rCBF also appears to correlate well with regional measurements of brain tissue oxygenation. Currently, such monitoring should be considered experimental, requiring much further evaluation prior to widespread adoption.
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Affiliation(s)
- François Mathieu
- 1 Division of Neurosurgery, University of Toronto, Toronto, Ontario, Canada.,2 Division of Anesthesia, Addenbrooke's Hospital, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Abdelhakim Khellaf
- 3 Faculty of Medicine, McGill University, Montreal, Quebec, Canada.,4 Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Eric P Thelin
- 4 Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,5 Department of Clinical Neuroscience, Karolinska Institute, Stockholm, Sweden
| | - Frederick A Zeiler
- 2 Division of Anesthesia, Addenbrooke's Hospital, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,6 Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,7 Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
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Tsitsopoulos PP, Abu Hamdeh S, Marklund N. Current Opportunities for Clinical Monitoring of Axonal Pathology in Traumatic Brain Injury. Front Neurol 2017; 8:599. [PMID: 29209266 PMCID: PMC5702013 DOI: 10.3389/fneur.2017.00599] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/05/2017] [Accepted: 10/25/2017] [Indexed: 01/14/2023] Open
Abstract
Traumatic brain injury (TBI) is a multidimensional and highly complex disease commonly resulting in widespread injury to axons, due to rapid inertial acceleration/deceleration forces transmitted to the brain during impact. Axonal injury leads to brain network dysfunction, significantly contributing to cognitive and functional impairments frequently observed in TBI survivors. Diffuse axonal injury (DAI) is a clinical entity suggested by impaired level of consciousness and coma on clinical examination and characterized by widespread injury to the hemispheric white matter tracts, the corpus callosum and the brain stem. The clinical course of DAI is commonly unpredictable and it remains a challenging entity with limited therapeutic options, to date. Although axonal integrity may be disrupted at impact, the majority of axonal pathology evolves over time, resulting from delayed activation of complex intracellular biochemical cascades. Activation of these secondary biochemical pathways may lead to axonal transection, named secondary axotomy, and be responsible for the clinical decline of DAI patients. Advances in the neurocritical care of TBI patients have been achieved by refinements in multimodality monitoring for prevention and early detection of secondary injury factors, which can be applied also to DAI. There is an emerging role for biomarkers in blood, cerebrospinal fluid, and interstitial fluid using microdialysis in the evaluation of axonal injury in TBI. These biomarker studies have assessed various axonal and neuroglial markers as well as inflammatory mediators, such as cytokines and chemokines. Moreover, modern neuroimaging can detect subtle or overt DAI/white matter changes in diffuse TBI patients across all injury severities using magnetic resonance spectroscopy, diffusion tensor imaging, and positron emission tomography. Importantly, serial neuroimaging studies provide evidence for evolving axonal injury. Since axonal injury may be a key risk factor for neurodegeneration and dementias at long-term following TBI, the secondary injury processes may require prolonged monitoring. The aim of the present review is to summarize the clinical short- and long-term monitoring possibilities of axonal injury in TBI. Increased knowledge of the underlying pathophysiology achieved by advanced clinical monitoring raises hope for the development of novel treatment strategies for axonal injury in TBI.
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Affiliation(s)
- Parmenion P Tsitsopoulos
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden.,Hippokratio General Hospital, Aristotle University, Thessaloniki, Greece
| | - Sami Abu Hamdeh
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden
| | - Niklas Marklund
- Section of Neurosurgery, Department of Neuroscience, Uppsala University, Uppsala, Sweden.,Department of Clinical Sciences Lund, Neurosurgery, Skåne University Hospital, Lund University, Lund, Sweden
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Handbook of Bleeding and Coagulation for Neurosurgery. J Neurosurg Anesthesiol 2017. [DOI: 10.1097/ana.0000000000000264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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Handbook of Bleeding and Coagulation in Neurosurgery. J Neurosurg Anesthesiol 2017. [DOI: 10.1097/ana.0000000000000256] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/26/2022]
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KOIZUMI H, SUEHIRO E, FUJIYAMA Y, SUGIMOTO K, INOUE T, SUZUKI M. Update on intensive neuromonitoring for patients with traumatic brain injury: a review of the literature and the current situation. Neurol Med Chir (Tokyo) 2014; 54:870-7. [PMID: 25367587 PMCID: PMC4533348 DOI: 10.2176/nmc.ra.2014-0168] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/02/2014] [Accepted: 06/28/2014] [Indexed: 11/20/2022] Open
Abstract
Intracranial pressure (ICP) measurements are fundamental in the present protocols for intensive care of patients during the acute stage of severe traumatic brain injury. However, the latest report of a large scale randomized clinical trial indicated no association of ICP monitoring with any significant improvement in neurological outcome in severely head injured patients. Aggressive treatment of patients with therapeutic hypothermia during the acute stage of traumatic brain injury also failed to show any significant beneficial effects on clinical outcome. This lack of significant results in clinical trials has limited the therapeutic strategies available for treatment of severe traumatic brain injury. However, combined application of different types of neuromonitoring, including ICP measurement, may have potential benefits for understanding the pathophysiology of damaged brains. The combination of monitoring techniques is expected to increase the precision of the data and aid in prevention of secondary brain damage, as well as assist in determining appropriate time periods for therapeutic interventions. In this study, we have characterized the techniques used to monitor patients during the acute severe traumatic brain injury stage, in order to establish the beneficial effects on outcome observed in clinical studies conducted in the past and to follow up any valuable clues that point to additional strategies for aggressive management of these patients.
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Affiliation(s)
- Hiroyasu KOIZUMI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Eiichi SUEHIRO
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Yuichi FUJIYAMA
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Kazutaka SUGIMOTO
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Takao INOUE
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
| | - Michiyasu SUZUKI
- Department of Neurosurgery, Yamaguchi University School of Medicine, Ube, Yamaguchi
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Stover JF. Contemporary view on neuromonitoring following severe traumatic brain injury. World J Crit Care Med 2012; 1:15-22. [PMID: 24701397 PMCID: PMC3956064 DOI: 10.5492/wjccm.v1.i1.15] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2011] [Revised: 10/27/2011] [Accepted: 12/21/2011] [Indexed: 02/06/2023] Open
Abstract
Evolving brain damage following traumatic brain injury (TBI) is strongly influenced by complex pathophysiologic cascades including local as well as systemic influences. To successfully prevent secondary progression of the primary damage we must actively search and identify secondary insults e.g. hypoxia, hypotension, uncontrolled hyperventilation, anemia, and hypoglycemia, which are known to aggravate existing brain damage. For this, we must rely on specific cerebral monitoring. Only then can we unmask changes which otherwise would remain hidden, and prevent adequate intensive care treatment. Apart from intracranial pressure (ICP) and calculated cerebral perfusion pressure (CPP), extended neuromonitoring (SjvO2, ptiO2, microdialysis, transcranial Doppler sonography, electrocorticography) also allows us to define individual pathologic ICP and CPP levels. This, in turn, will support our therapeutic decision-making and also allow a more individualized and flexible treatment concept for each patient. For this, however, we need to learn to integrate several dimensions with their own possible treatment options into a complete picture. The present review summarizes the current understanding of extended neuromonitoring to guide therapeutic interventions with the aim of improving intensive care treatment following severe TBI, which is the basis for ameliorated outcome.
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Affiliation(s)
- John F Stover
- John F Stover, Surgical Intensive Care Medicine, University Hospital Zürich, Rämistrasse 100, 8091 Zürich, Switzerland
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Rosenthal G, Sanchez-Mejia RO, Phan N, Hemphill JC, Martin C, Manley GT. Incorporating a parenchymal thermal diffusion cerebral blood flow probe in bedside assessment of cerebral autoregulation and vasoreactivity in patients with severe traumatic brain injury. J Neurosurg 2010; 114:62-70. [PMID: 20707619 DOI: 10.3171/2010.6.jns091360] [Citation(s) in RCA: 77] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
Abstract
OBJECT Cerebral autoregulation may be altered after traumatic brain injury (TBI). Recent evidence suggests that patients' autoregulatory status following severe TBI may influence cerebral perfusion pressure management. The authors evaluated the utility of incorporating a recently upgraded parenchymal thermal diffusion probe for the measurement of cerebral blood flow (CBF) in the neurointensive care unit for assessing cerebral autoregulation and vasoreactivity at bedside. METHODS The authors evaluated 20 patients with severe TBI admitted to San Francisco General Hospital who underwent advanced neuromonitoring. Patients had a parenchymal thermal diffusion probe placed for continuous bedside monitoring of local CBF ((loc)CBF) in addition to the standard intracranial pressure and brain tissue oxygen tension (P(bt)O(2)) monitoring. The CBF probes were placed in the white matter using a separate cranial bolt. A pressure challenge, whereby mean arterial pressure (MAP) was increased by about 10 mm Hg, was performed in all patients to assess autoregulation. Cerebral CO(2) vasoreactivity was assessed with a hyperventilation challenge. Local cerebral vascular resistance ((loc)CVR) was calculated by dividing cerebral perfusion pressure by (loc)CBF. Local cerebral vascular resistance normalized to baseline ((loc)CVR(normalized)) was also calculated for the MAP and hyperventilation challenges. RESULTS In all cases, bedside measurement of (loc)CBF using a cranial bolt in patients with severe TBI resulted in correct placement in the white matter with a low rate of complications. Mean (loc)CBF decreased substantially with hyperventilation challenge (-7 ± 8 ml/100 g/min, p = 0.0002) and increased slightly with MAP challenge (1 ± 7 ml/100 g/min, p = 0.17). Measurements of (loc)CBF following MAP and hyperventilation challenges can be used to calculate (loc)CVR. In 83% of cases, (loc)CVR increased during a hyperventilation challenge (mean change +3.5 ± 3.8 mm Hg/ml/100 g/min, p = 0.0002), indicating preserved cerebral CO(2) vasoreactivity. In contrast, we observed a more variable response of (loc)CVR to MAP challenge, with increased (loc)CVR in only 53% of cases during a MAP challenge (mean change -0.17 ± 3.9 mm Hg/ml/100 g/min, p = 0.64) indicating that in many cases autoregulation was impaired following severe TBI. CONCLUSIONS Use of the Hemedex thermal diffusion probe appears to be a safe and feasible method that enables continuous monitoring of CBF at the bedside. Cerebral autoregulation and CO(2) vasoreactivity can be assessed in patients with severe TBI using the CBF probe by calculating (loc)CVR in response to MAP and hyperventilation challenges. Determining whether CVR increases or decreases with a MAP challenge ((loc)CVR(normalized)) may be a simple provocative test to determine patients' autoregulatory status following severe TBI and helping to optimize CPP management.
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Affiliation(s)
- Guy Rosenthal
- Department of Neurosurgery, University of California, San Francisco, California, USA
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Current world literature. Curr Opin Anaesthesiol 2010; 23:283-93. [PMID: 20404787 DOI: 10.1097/aco.0b013e328337578e] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/19/2022]
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