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Yu Y, Lettow I, Roedl K, Jarczak D, Pinnschmidt H, Reichenspurner H, Bernhardt AM, Söffker G, Schrage B, Haar M, Weber T, Frings D, Kluge S, Fischer M. Association of early changes in arterial carbon dioxide with acute brain injury in adult patients with extracorporeal membrane oxygenation: A ten-year retrospective study in a German tertiary care hospital. J Crit Care 2024; 84:154880. [PMID: 39024824 DOI: 10.1016/j.jcrc.2024.154880] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/30/2023] [Revised: 06/21/2024] [Accepted: 07/12/2024] [Indexed: 07/20/2024]
Abstract
PURPOSE To assess the association between fluctuations of arterial carbon dioxide early after start of extracorporeal membrane oxygenation (ECMO) with intracranial hemorrhage (ICH) or ischemic stroke (IS). MATERIALS AND METHODS This single-center retrospective study included patients who required ECMO for circulatory or respiratory failure between January 2011 and April 2021 and for whom a cerebral computed tomography (cCT) scan was available. Multivariable logistic regression models were fitted to evaluate the association between the relative change of arterial carbon dioxide (RelΔPaCO2) and ICH, IS or a composite of ICH, IS, and mortality. RESULTS In 618 patients (venovenous ECMO: n = 295; venoarterial ECMO: n = 323) ICH occurred more frequently in patients with respiratory failure (19.0%) compared with patients with circulatory failure (6.8%). Conversely, the incidence of IS was higher in patients with circulatory failure (19.2%) compared with patients with respiratory failure (4.7%). While patients with ECMO for respiratory failure were more likely to have ICH (OR 3.683 [95% CI: 1.855;7.309], p < 0.001), they had a lower odds for IS (OR 0.360 [95%CI: 0.158;0.820], p = 0.015) compared with patients with circulatory failure. There was no significant association between RelΔPaCO2 and ICH or IS. CONCLUSIONS Irrespective of the indication for ECMO, we did not find a significant association between the relative change in PaCO2 early after ECMO initiation and acute brain injury. Aside from early PaCO2 decline at cannulation, future studies should address fluctuations of PaCO2 throughout the course of ECMO support and their effect on acute brain injury.
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Affiliation(s)
- Yuanyuan Yu
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Iris Lettow
- Department of Neurology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Kevin Roedl
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Dominik Jarczak
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hans Pinnschmidt
- Institute of Medical Biometry and Epidemiology, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Hermann Reichenspurner
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Alexander M Bernhardt
- Department of Cardiovascular Surgery, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Gerold Söffker
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Benedikt Schrage
- Department of Cardiology, University Heart and Vascular Center Hamburg, Hamburg, Germany; German Center for Cardiovascular Research (DZHK), Partner Site Hamburg/Lübeck/Kiel, Germany
| | - Markus Haar
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Theresa Weber
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Daniel Frings
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Stefan Kluge
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany
| | - Marlene Fischer
- Department of Intensive Care Medicine, University Medical Center Hamburg-Eppendorf, Hamburg, Germany.
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Madarasz A, Xin L, Proulx ST. Clearance of erythrocytes from the subarachnoid space through cribriform plate lymphatics in female mice. EBioMedicine 2024; 107:105295. [PMID: 39178745 PMCID: PMC11388277 DOI: 10.1016/j.ebiom.2024.105295] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/21/2024] [Revised: 08/02/2024] [Accepted: 08/06/2024] [Indexed: 08/26/2024] Open
Abstract
BACKGROUND Atraumatic subarachnoid haemorrhage (SAH) is associated with high morbidity and mortality. Proposed mechanisms for red blood cell (RBC) clearance from the subarachnoid space (SAS) are erythrolysis, erythrophagocytosis or through efflux along cerebrospinal fluid (CSF) drainage routes. We aimed to elucidate the mechanisms of RBC clearance from the SAS to identify targetable efflux pathways. METHODS Autologous fluorescently-labelled RBCs along with PEGylated 40 kDa near-infrared tracer (P40D800) were infused via the cisterna magna (i.c.m.) in female reporter mice for lymphatics or for resident phagocytes. Drainage pathways for RBCs to extracranial lymphatics were evaluated by in vivo and in situ near-infrared imaging and by immunofluorescent staining on decalcified cranial tissue or dural whole-mounts. FINDINGS RBCs drained to the deep cervical lymph nodes 15 min post i.c.m. infusion, showing similar dynamics as P40D800 tracer. Postmortem in situ imaging and histology showed perineural accumulations of RBCs around the optic and olfactory nerves. Numerous RBCs cleared through the lymphatics of the cribriform plate, whilst histology showed no relevant fast RBC clearance through dorsal dural lymphatics or by tissue-resident macrophage-mediated phagocytosis. INTERPRETATION This study provides evidence for rapid RBC drainage through the cribriform plate lymphatic vessels, whilst neither fast RBC clearance through dorsal dural lymphatics nor through spinal CSF efflux or phagocytosis was observed. Similar dynamics of P40D800 and RBCs imply open pathways for clearance that do not impose a barrier for RBCs. This finding suggests further evaluation of the cribriform plate lymphatic function and potential pharmacological targeting in models of SAH. FUNDING Swiss National Science Foundation (310030_189226), SwissHeart (FF191155).
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Affiliation(s)
- Adrian Madarasz
- Theodor Kocher Institute, University of Bern, Bern, Switzerland
| | - Li Xin
- Theodor Kocher Institute, University of Bern, Bern, Switzerland
| | - Steven T Proulx
- Theodor Kocher Institute, University of Bern, Bern, Switzerland.
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Malinova V, Kranawetter B, Tuzi S, Moerer O, Rohde V, Mielke D. Interaction of Optimal Cerebral Perfusion Pressure with Early Brain Injury and its Impact on Ischemic Complications and Outcome Following Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2024; 40:879-885. [PMID: 37726549 PMCID: PMC11147945 DOI: 10.1007/s12028-023-01822-1] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/24/2023] [Accepted: 07/27/2023] [Indexed: 09/21/2023]
Abstract
BACKGROUND Cerebral autoregulation is impaired early on after aneurysmal subarachnoid hemorrhage (aSAH). The study objective was to explore the pressure reactivity index (PRx) and cerebral perfusion pressure (CPP) in the earliest phase after aneurysm rupture and to address the question of whether an optimal CPP (CPPopt)-targeted management is associated with less severe early brain injury (EBI). METHODS Patients with aSAH admitted between 2012 and 2020 were retrospectively included in this observational cohort study. The PRx was calculated as a correlation coefficient between intracranial pressure and mean arterial pressure. By plotting the PRx versus CPP, CPP correlating the lowest PRx value was identified as CPPopt. EBI was assessed by applying the Subarachnoid Hemorrhage Early Brain Edema Score (SEBES) on day 3 after ictus. An SEBES ≥ 3 was considered severe EBI. RESULTS In 90 of 324 consecutive patients with aSAH, intracranial pressure monitoring was performed ≥ 7 days, allowing for PRx calculation and CPPopt determination. Severe EBI was associated with larger mean deviation of CPP from CPPopt 72 h after ictus (r = 0.22, p = 0.03). Progressive edema requiring decompressive hemicraniectomy was associated with larger deviation of CPP from CPPopt on day 2 (r = 0.23, p = 0.02). The higher the difference of CPP from CPPopt on day 3 the higher the mortality rate (r = 0.31, p = 0.04). CONCLUSIONS Patients with CPP near to the calculated CPPopt in the early phase after aSAH experienced less severe EBI, less frequently received decompressive hemicraniectomy, and exhibited a lower mortality rate. A prospective evaluation of CPPopt-guided management starting in the first days after ictus is needed to confirm the clinical validity of this concept.
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Affiliation(s)
- Vesna Malinova
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany.
| | - Beate Kranawetter
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Sheri Tuzi
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Onnen Moerer
- Department of Anesthesiology, University Medical Center Göttingen, Göttingen, Germany
| | - Veit Rohde
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
| | - Dorothee Mielke
- Department of Neurosurgery, University Medical Center Göttingen, Georg-August-University, Robert-Koch-Straße 40, 37075, Göttingen, Germany
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Svedung Wettervik TM, Hånell A, Howells T, Ronne-Engström E, Lewén A, Enblad P. Individualized Autoregulation-Derived Cerebral Perfusion Targets in Aneurysmal Subarachnoid Hemorrhage: A New Therapeutic Avenue? J Intensive Care Med 2024:8850666241252415. [PMID: 38706245 DOI: 10.1177/08850666241252415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background: Cerebral perfusion pressure (CPP) is an important target in aneurysmal subarachnoid hemorrhage (aSAH), but it does not take into account autoregulatory disturbances. The pressure reactivity index (PRx) and the CPP with the optimal PRx (CPPopt) are new variables that may capture these pathomechanisms. In this study, we investigated the effect on the outcome of certain combinations of CPP or ΔCPPopt (actual CPP-CPPopt) with the concurrent autoregulatory status (PRx) after aSAH. Methods: This observational study included 432 aSAH patients, treated in the neurointensive care unit, at Uppsala University Hospital, Sweden. Functional outcome (GOS-E) was assessed 1-year postictus. Heatmaps of the percentage of good monitoring time (%GMT) of PRx/CPP and PRx/ΔCPPopt combinations in relation to GOS-E were created to visualize the association between these variables and outcome. Results: In the heatmap of the %GMT of PRx/CPP, the combination of lower CPP with higher PRx values was more strongly associated with lower GOS-E. The tolerance for lower CPP values increased with lower PRx values until a threshold of -0.50. However, for decreasing PRx below -0.50, there was a gradual reduction in the tolerance for lower CPP. In the heatmap of the %GMT of PRx/ΔCPPopt, the combination of negative ΔCPPopt with higher PRx values was strongly associated with lower GOS-E. In particular, negative ΔCPPopt together with PRx above +0.50 correlated with worse outcomes. In addition, there was a transition toward an unfavorable outcome when PRx went below -0.50, particularly if ΔCPPopt was negative. Conclusions: The PRx levels influenced the association between CPP/ΔCPPopt and outcome. Thus, this variable could be used to individualize a safe CPP-/ΔCPPopt-range.
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Affiliation(s)
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Svedung Wettervik T, Howells T, Hånell A, Lewén A, Enblad P. The Optimal pressure reactivity index range is disease-specific: A comparison between aneurysmal subarachnoid hemorrhage and traumatic brain injury. J Clin Monit Comput 2024:10.1007/s10877-024-01168-9. [PMID: 38702589 DOI: 10.1007/s10877-024-01168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Impaired cerebral pressure autoregulation is common and detrimental after acute brain injuries. Based on the prevalence of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH) patients compared to traumatic brain injury (TBI), we hypothesized that the type of autoregulatory disturbance and the optimal PRx range may differ between these two conditions. The aim of this study was to determine the optimal PRx ranges in relation to functional outcome following aSAH and TBI, respectively. METHODS In this observational study, 487 aSAH patients and 413 TBI patients, treated in the neurointensive care, Uppsala, Sweden, between 2008 and 2018, were included. The percentage of good monitoring time (%GMT) of PRx was calculated within 8 intervals covering the range from -1.0 to + 1.0, and analyzed in relation to favorable outcome (GOS-E 5 to 8). RESULTS In multiple logistic regressions, a higher %GMTs of PRx in the intervals -1.0 to -0.5 and + 0.75 to + 1.0 were independently associated with a lower rate of favorable outcome in the aSAH cohort. In a similar analysis in the TBI cohort, only positive PRx in the interval + 0.75 to + 1.0 was independently associated with a lower rate of favorable outcome. CONCLUSION Extreme PRx values in both directions were unfavorable in aSAH, possibly as high PRx could indicate proximal vasospasm with exhausted distal vasodilatory reserve, while very negative PRx could reflect myogenic hyperreactivity with suppressed cerebral blood flow. Only elevated PRx was unfavorable in TBI, possibly as pressure passive vessels may be a more predominant pathomechanism in this disease.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Chen L, Fan B, Wang F, Song Y, Wang X, Meng Y, Chen Y, Xia Q, Sun J. Research Progress in Pharmacological Effects and Mechanisms of Angelica sinensis against Cardiovascular and Cerebrovascular Diseases. Molecules 2024; 29:2100. [PMID: 38731591 PMCID: PMC11085520 DOI: 10.3390/molecules29092100] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/20/2024] [Revised: 04/22/2024] [Accepted: 04/25/2024] [Indexed: 05/13/2024] Open
Abstract
Angelica sinensis (Oliv.) Diels (A. sinensis) is a medicinal and edible values substance, which could promote blood circulation and enrich blood. It possesses rich chemical components and nutrients, which have significant therapeutic effects on cardiovascular and cerebrovascular diseases. It is commonly used for the prevention and treatment of cardiovascular and cerebrovascular diseases in the elderly, especially in improving ischemic damage to the heart and brain, protecting vascular cells, and regulating inflammatory reactions. This article reviews the main pharmacological effects and clinical research of A. sinensis on cardiovascular and cerebrovascular diseases in recent years, explores the effect of its chemical components on cardiovascular and cerebrovascular diseases by regulating the expression of functional proteins and inhibiting inflammation, anti-apoptosis, and antioxidant mechanisms. It provides a reference for further research on A. sinensis and the development of related drugs. It provides a new reference direction for the in-depth research and application of A. sinensis in the prevention, improvement, and treatment of cardiovascular and cerebrovascular diseases.
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Affiliation(s)
- Linlin Chen
- School of Management, Liaoning University of International Business and Economics, Dalian 116052, China; (L.C.); (Y.S.); (X.W.); (Y.M.); (Y.C.)
- Risk Assessment Laboratory of Agricultural Products Processing Quality and Safety, Key Laboratory of Agricultural Products Quality and Safety Collection, Storage and Transportation Control, Ministry of Agriculture and Rural Affairs, Institute of Food Science and Technology, Chinese Academy of Agricultural Sciences, Beijing 100193, China; (B.F.); (F.W.)
| | - Bei Fan
- Risk Assessment Laboratory of Agricultural Products Processing Quality and Safety, Key Laboratory of Agricultural Products Quality and Safety Collection, Storage and Transportation Control, Ministry of Agriculture and Rural Affairs, Institute of Food Science and Technology, Chinese Academy of Agricultural Sciences, Beijing 100193, China; (B.F.); (F.W.)
| | - Fengzhong Wang
- Risk Assessment Laboratory of Agricultural Products Processing Quality and Safety, Key Laboratory of Agricultural Products Quality and Safety Collection, Storage and Transportation Control, Ministry of Agriculture and Rural Affairs, Institute of Food Science and Technology, Chinese Academy of Agricultural Sciences, Beijing 100193, China; (B.F.); (F.W.)
| | - Yang Song
- School of Management, Liaoning University of International Business and Economics, Dalian 116052, China; (L.C.); (Y.S.); (X.W.); (Y.M.); (Y.C.)
| | - Xizhi Wang
- School of Management, Liaoning University of International Business and Economics, Dalian 116052, China; (L.C.); (Y.S.); (X.W.); (Y.M.); (Y.C.)
| | - Ying Meng
- School of Management, Liaoning University of International Business and Economics, Dalian 116052, China; (L.C.); (Y.S.); (X.W.); (Y.M.); (Y.C.)
| | - Yumin Chen
- School of Management, Liaoning University of International Business and Economics, Dalian 116052, China; (L.C.); (Y.S.); (X.W.); (Y.M.); (Y.C.)
| | - Qing Xia
- Biology Institute, Qilu University of Technology (Shandong Academy of Sciences), Jinan 250013, China
| | - Jing Sun
- School of Management, Liaoning University of International Business and Economics, Dalian 116052, China; (L.C.); (Y.S.); (X.W.); (Y.M.); (Y.C.)
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Kataria K, Panda NB, Luthra A, Mahajan S, Bhagat H, Chauhan R, Soni S, Jangra K, Kaloria N, Paul S, Bloria S, Gupta S, Chhabra R. Assessment of impaired cerebral autoregulation and its correlation with neurological outcome in aneurysmal subarachnoid hemorrhage: A prospective and observational study. Surg Neurol Int 2023; 14:290. [PMID: 37680917 PMCID: PMC10481860 DOI: 10.25259/sni_25_2023] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/08/2023] [Accepted: 07/11/2023] [Indexed: 09/09/2023] Open
Abstract
Background Cerebral autoregulation (CA) is crucial for the maintenance of cerebral homeostasis. It can be assessed by measuring transient hyperemic response ratio (THRR) using transcranial Doppler (TCD). We aimed at assessing the incidence of impaired CA (ICA) and its correlation with the neurological outcome in patients with aneurysmal subarachnoid hemorrhage (aSAH). Methods One hundred consecutive patients with aSAH scheduled for aneurysmal clipping were enrolled in this prospective and observational study. Preoperative and consecutive 5-day postoperative THRR measurements were taken. Primary objective of the study was to detect the incidence of ICA and its correlation with vasospasm (VS) postclipping, and neurological outcome at discharge and 1, 3, and 12 months was secondary objectives. Results ICA (THRR < 1.09) was observed in 69 patients preoperatively, 74 patients on the 1st and 2nd postoperative day, 76 patients on 3rd postoperative day, and 78 patients on 4th and 5th postoperative day. Significant VS was seen in 13.4% and 61.5% of patients with intact THRR and deranged THRR, respectively (P < 0.000). Out of 78 patients who had ICA, 42 patients (53.8%) at discharge, 60 patients (76.9%) at 1 month, 54 patients (69.2%) at 3 month, and 55 patients (70.5%) at 12 months had unfavorable neurological outcome significantly more than those with preserved CA. Conclusion Incidence of ICA assessed in aSAH patients varies from 69% to 78% in the perioperative period. The deranged CA was associated with significantly poor neurological outcome. Therefore, CA assessment using TCD-based THRR provides a simple, noninvasive bedside approach for predicting neurological outcome in aSAH.
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Affiliation(s)
- Ketan Kataria
- Department of Anaesthesiology, Critical Care and Pain, Tata Memorial Centre, Mumbai, India
| | - Nidhi Bidyut Panda
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ankur Luthra
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shalvi Mahajan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Hemant Bhagat
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajeev Chauhan
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shiv Soni
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kiran Jangra
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Narender Kaloria
- Department of Anaesthesia and Intensive Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shamik Paul
- Department of Anaesthesiology and Critical Care, Armed Forces Medical College (AFMC), Pune, India
| | - Summit Bloria
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Shailesh Gupta
- Department of Anaesthesia and Intensive Care, Division of Neuroanesthesia, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rajesh Chhabra
- Department of Neurosurgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
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Gouvea Bogossian E, Battaglini D, Fratino S, Minini A, Gianni G, Fiore M, Robba C, Taccone FS. The Role of Brain Tissue Oxygenation Monitoring in the Management of Subarachnoid Hemorrhage: A Scoping Review. Neurocrit Care 2023; 39:229-240. [PMID: 36802011 DOI: 10.1007/s12028-023-01680-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/20/2022] [Accepted: 01/19/2023] [Indexed: 02/19/2023]
Abstract
Monitoring of brain tissue oxygenation (PbtO2) is an important component of multimodal monitoring in traumatic brain injury. Over recent years, use of PbtO2 monitoring has also increased in patients with poor-grade subarachnoid hemorrhage (SAH), particularly in those with delayed cerebral ischemia. The aim of this scoping review was to summarize the current state of the art regarding the use of this invasive neuromonitoring tool in patients with SAH. Our results showed that PbtO2 monitoring is a safe and reliable method to assess regional cerebral tissue oxygenation and that PbtO2 represents the oxygen available in the brain interstitial space for aerobic energy production (i.e., the product of cerebral blood flow and the arterio-venous oxygen tension difference). The PbtO2 probe should be placed in the area at risk of ischemia (i.e., in the vascular territory in which cerebral vasospasm is expected to occur). The most widely used PbtO2 threshold to define brain tissue hypoxia and initiate specific treatment is between 15 and 20 mm Hg. PbtO2 values can help identify the need for or the effects of various therapies, such as hyperventilation, hyperoxia, induced hypothermia, induced hypertension, red blood cell transfusion, osmotic therapy, and decompressive craniectomy. Finally, a low PbtO2 value is associated with a worse prognosis, and an increase of the PbtO2 value in response to treatment is a marker of good outcome.
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Affiliation(s)
- Elisa Gouvea Bogossian
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium.
| | - Denise Battaglini
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Medicine, University of Barcelona, Barcelona, Spain
| | - Sara Fratino
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Andrea Minini
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Giuseppina Gianni
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Marco Fiore
- Department of Women, Child, and General and Specialized Surgery, University of Campania Luigi Vanvitelli, Naples, Italy
| | - Chiara Robba
- Anesthesia and Intensive Care, Instituto di Ricovero e Cura a carattere scientifico for Oncology and Neuroscience, San Martino Policlinico Hospital, Genoa, Italy
- Department of Surgical Sciences and Integrated Diagnostics, University of Genoa, Genoa, Italy
| | - Fabio Silvio Taccone
- Department of Intensive Care, Université Libre de Bruxelles, Erasme Hospital, Route de Lennik, 808, 1070, Brussels, Belgium
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Hofmann BB, Rubbert C, Beseoglu K. Cerebral Autoregulation: Don't go with the Flow, be the Flow; Author's Response. Neurocrit Care 2023; 39:266-267. [PMID: 37291417 PMCID: PMC10499668 DOI: 10.1007/s12028-023-01759-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/13/2023] [Accepted: 05/16/2023] [Indexed: 06/10/2023]
Affiliation(s)
- Björn B Hofmann
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany.
| | - Christian Rubbert
- Department of Diagnostic and Interventional Radiology, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
| | - Kerim Beseoglu
- Department of Neurosurgery, Medical Faculty and University Hospital Düsseldorf, Heinrich-Heine-University, Düsseldorf, Germany
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Rass V, Kindl P, Lindner A, Kofler M, Altmann K, Putnina L, Ianosi BA, Schiefecker AJ, Beer R, Pfausler B, Helbok R. Blood Pressure Changes in Association with Nimodipine Therapy in Patients with Spontaneous Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:104-115. [PMID: 37308727 PMCID: PMC10499738 DOI: 10.1007/s12028-023-01760-y] [Citation(s) in RCA: 3] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/21/2022] [Accepted: 05/16/2023] [Indexed: 06/14/2023]
Abstract
BACKGROUND Nimodipine is recommended to prevent delayed cerebral ischemia in patients with spontaneous subarachnoid hemorrhage (SAH). Here, we studied hemodynamic side effects of different nimodipine formulations (per os [PO] and intravenous [IV]) in patients with SAH undergoing continuous blood pressure monitoring. METHODS This observational cohort study includes consecutive patients with SAH (271 included in the IV group, 49 in the PO group) admitted to a tertiary care center between 2010 and 2021. All patients received prophylactic IV or PO nimodipine. Hemodynamic responses were evaluated based on median values within the first hour after continuous IV nimodipine initiation or PO nimodipine application (601 intakes within 15 days). Significant changes were defined as > 10% drop in systolic blood pressure (SBP) or diastolic blood pressure from baseline (median values 30 min before nimodipine application). With the use of multivariable logistic regression, risk factors associated with SBP drops were identified. RESULTS Patients were admitted with a median Hunt & Hess score of 3 (2-5; IV 3 [2-5], PO 1 [1-2], p < 0.001) and were 58 (49-69) years of age. Initiation of IV nimodipine was associated with a > 10% SBP drop in 30% (81/271) of patients, with a maximum effect after 15 min. A start or increase in noradrenaline was necessary in 136/271 (50%) patients, and colloids were administered in 25/271 (9%) patients within 1 h after IV nimodipine initiation. SBP drops > 10% occurred after 53/601 (9%) PO nimodipine intakes, with a maximum effect after 30-45 min in 28/49 (57%) patients. Noradrenaline application was uncommon (3% before and 4% after nimodipine PO intake). Hypotensive episodes to an SBP < 90 mm Hg were not observed after IV or PO nimodipine application. In multivariable analysis, only a higher SBP at baseline was associated with a > 10% drop in SBP after IV (p < 0.001) or PO (p = 0.001) nimodipine application, after adjusting for the Hunt & Hess score on admission, age, sex, mechanical ventilation, days after intensive care unit admission, and delayed cerebral ischemia. CONCLUSIONS Significant drops in SBP occur in one third of patients after the start of IV nimodipine and after every tenth PO intake. Early recognition and counteracting with vasopressors or fluids seems necessary to prevent hypotensive episodes.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Philipp Kindl
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Klaus Altmann
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
- Department of Neurology, Kepler University Hospital, Johannes Kepler University Linz, Linz, Austria
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11
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Sanchez-Porras R, Ramírez-Cuapio FL, Hecht N, Seule M, Díaz-Peregrino R, Unterberg A, Woitzik J, Dreier JP, Sakowitz OW, Santos E. Cerebrovascular Pressure Reactivity According to Long-Pressure Reactivity Index During Spreading Depolarizations in Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2023; 39:135-144. [PMID: 36697998 PMCID: PMC10499750 DOI: 10.1007/s12028-022-01669-y] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 12/19/2022] [Indexed: 01/26/2023]
Abstract
BACKGROUND Spreading depolarization (SD) has been linked to the impairment of neurovascular coupling. However, the association between SD occurrence and cerebrovascular pressure reactivity as a surrogate of cerebral autoregulation (CA) remains unclear. Therefore, we analyzed CA using the long-pressure reactivity index (L-PRx) during SDs in patients with aneurysmal subarachnoid hemorrhage (aSAH). METHODS A retrospective study of patients with aSAH who were recruited at two centers, Heidelberg (HD) and Berlin (BE), was performed. Continuous monitoring of mean arterial pressure (MAP) and intracranial pressure (ICP) was recorded. ICP was measured using an intraparenchymal probe in HD patients and was measure in BE patients through external ventricular drainage. Electrocorticographic (ECoG) activity was continuously recorded between 3 and 13 days after hemorrhage. Autoregulation according to L-PRx was calculated as a moving linear Pearson's correlation of 20-min averages of MAP and ICP. For every identified SD, 60-min intervals of L-PRx were averaged, plotted, and analyzed depending on SD occurrence. Random L-PRx recording periods without SDs served as the control. RESULTS A total of 19 patients (HD n = 14, BE n = 5, mean age 50.4 years, 9 female patients) were monitored for a mean duration of 230.4 h (range 96-360, STD ± 69.6 h), during which ECoG recordings revealed a total number of 277 SDs. Of these, 184 represented a single SD, and 93 SDs presented in clusters. In HD patients, mean L-PRx values were 0.12 (95% confidence interval [CI] 0.11-0.13) during SDs and 0.07 (95% CI 0.06-0.08) during control periods (p < 0.001). Similarly, in BE patients, a higher L-PRx value of 0.11 (95% CI 0.11-0.12) was detected during SDs than that during control periods (0.08, 95% CI 0.07-0.09; p < 0.001). In a more detailed analysis, CA changes registered through an intraparenchymal probe (HD patients) revealed that clustered SD periods were characterized by signs of more severely impaired CA (L-PRx during SD in clusters: 0.23 [95% CI 0.20-0.25]; single SD: 0.09 [95% CI 0.08-0.10]; control periods: 0.07 [95% CI 0.06-0.08]; p < 0.001). This group also showed significant increases in ICP during SDs in clusters compared with single SD and control periods. CONCLUSIONS Neuromonitoring for simultaneous assessment of cerebrovascular pressure reactivity using 20-min averages of MAP and ICP measured by L-PRx during SD events is feasible. SD occurrence was associated with significant increases in L-PRx values indicative of CA disturbances. An impaired CA was found during SD in clusters when using an intraparenchymal probe. This preliminary study validates the use of cerebrovascular reactivity indices to evaluate CA disturbances during SDs. Our results warrant further investigation in larger prospective patient cohorts.
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Affiliation(s)
- Renan Sanchez-Porras
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Francisco L Ramírez-Cuapio
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Nils Hecht
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
| | - Martin Seule
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Department of Neurosurgery, Kantonsspital St. Gallen, St. Gallen, Switzerland
| | - Roberto Díaz-Peregrino
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Andreas Unterberg
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
| | - Johannes Woitzik
- Department of Neurosurgery, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany
| | - Jens P Dreier
- Center for Stroke Research Berlin, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Department of Experimental Neurology, Berlin Institute of Health, Charité-Universitätsmedizin Berlin, Corporate Member of Freie Universität Berlin, Humboldt-Universität zu Berlin, Berlin, Germany
- Bernstein Center for Computational Neuroscience Berlin, Berlin, Germany
- Einstein Center for Neurosciences Berlin, Berlin, Germany
| | - Oliver W Sakowitz
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany
- Neurosurgery Center Ludwigsburg-Heilbronn, RKH Klinikum Ludwigsburg, Ludwigsburg, Germany
| | - Edgar Santos
- Department of Neurosurgery, Heidelberg University Hospital, Ruprecht Karls University of Heidelberg, Heidelberg, Germany.
- Department of Neurosurgery, Evangelisches Krankenhaus Oldenburg, Carl von Ossietzky University of Oldenburg, Oldenburg, Germany.
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12
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Kastenholz N, Megjhani M, Conzen-Dilger C, Albanna W, Veldeman M, Nametz D, Kwon SB, Schulze-Steinen H, Ridwan H, Clusmann H, Schubert GA, Park S, Weiss M. The oxygen reactivity index indicates disturbed local perfusion regulation after aneurysmal subarachnoid hemorrhage: an observational cohort study. Crit Care 2023; 27:235. [PMID: 37312192 PMCID: PMC10265851 DOI: 10.1186/s13054-023-04452-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/10/2023] [Accepted: 04/19/2023] [Indexed: 06/15/2023] Open
Abstract
BACKGROUND Cerebral autoregulation (CA) can be impaired in patients with delayed cerebral ischemia (DCI) after aneurysmal subarachnoid hemorrhage (aSAH). The Pressure Reactivity Index (PRx, correlation of blood pressure and intracranial pressure) and Oxygen Reactivity Index (ORx, correlation of cerebral perfusion pressure and brain tissue oxygenation, PbtO2) are both believed to estimate CA. We hypothesized that CA could be poorer in hypoperfused territories during DCI and that ORx and PRx may not be equally effective in detecting such local variances. METHODS ORx and PRx were compared daily in 76 patients with aSAH with or without DCI until the time of DCI diagnosis. The ICP/PbtO2-probes of DCI patients were retrospectively stratified by being in or outside areas of hypoperfusion via CT perfusion image, resulting in three groups: DCI + /probe + (DCI patients, probe located inside the hypoperfused area), DCI + /probe- (probe outside the hypoperfused area), DCI- (no DCI). RESULTS PRx and ORx were not correlated (r = - 0.01, p = 0.56). Mean ORx but not PRx was highest when the probe was located in a hypoperfused area (ORx DCI + /probe + 0.28 ± 0.13 vs. DCI + /probe- 0.18 ± 0.15, p < 0.05; PRx DCI + /probe + 0.12 ± 0.17 vs. DCI + /probe- 0.06 ± 0.20, p = 0.35). PRx detected poorer autoregulation during the early phase with relatively higher ICP (days 1-3 after hemorrhage) but did not differentiate the three groups on the following days when ICP was lower on average. ORx was higher in the DCI + /probe + group than in the other two groups from day 3 onward. ORx and PRx did not differ between patients with DCI, whose probe was located elsewhere, and patients without DCI (ORx DCI + /probe- 0.18 ± 0.15 vs. DCI- 0.20 ± 0.14; p = 0.50; PRx DCI + /probe- 0.06 ± 0.20 vs. DCI- 0.08 ± 0.17, p = 0.35). CONCLUSIONS PRx and ORx are not interchangeable measures of autoregulation, as they likely measure different homeostatic mechanisms. PRx represents the classical cerebrovascular reactivity and might be better suited to detect disturbed autoregulation during phases with moderately elevated ICP. Autoregulation may be poorer in territories affected by DCI. These local perfusion disturbances leading up to DCI may be more readily detected by ORx than PRx. Further research should investigate their robustness to detect DCI and to serve as a basis for autoregulation-targeted treatment after aSAH.
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Affiliation(s)
- Nick Kastenholz
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Murad Megjhani
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Daniel Nametz
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Soon Bin Kwon
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
| | - Henna Schulze-Steinen
- Department of Intensive Care Medicine and Perioperative Care, RWTH Aachen University, Aachen, Germany
| | - Hani Ridwan
- Department of Diagnostic and Interventional Neuroradiology, RWTH Aachen University, Aachen, Germany
| | - Hans Clusmann
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Gerrit Alexander Schubert
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland
| | - Soojin Park
- Program for Hospital and Intensive Care Informatics, Department of Neurology, Columbia University Vagelos College of Physicians and Surgeons, New York City, NY, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York City, NY, USA
- Department of Biomedical Informatics, Columbia University, New York City, NY, USA
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany.
- Department of Neurosurgery, Cantonal Hospital Aarau, Tellstrasse 25, 5001, Aarau, Switzerland.
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13
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Chang JJ, Kepplinger D, Metter EJ, Felbaum DR, Mai JC, Armonda RA, Aulisi EF. Pressure reactivity index for early neuroprognostication in poor-grade subarachnoid hemorrhage. J Neurol Sci 2023; 450:120691. [PMID: 37267816 DOI: 10.1016/j.jns.2023.120691] [Citation(s) in RCA: 2] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/16/2023] [Revised: 05/18/2023] [Accepted: 05/21/2023] [Indexed: 06/04/2023]
Abstract
BACKGROUND Pressure reactivity index (PRx) utilizes moving correlation coefficients from intracranial pressure (ICP) and mean arterial pressures to evaluate cerebral autoregulation. We evaluated patients with poor-grade subarachnoid hemorrhage (SAH), identified their PRx trajectories over time, and identified threshold time points where PRx could be used for neuroprognostication. METHODS Patients with poor-grade SAH were identified and received continuous bolt ICP measurements. Dichotomized outcomes were based on ninety-day modified Rankin scores and disposition. Smoothed PRx trajectories for each patient were created to generate "candidate features" that looked at daily average PRx, cumulative first-order changes in PRx, and cumulative second-order changes in PRx. "Candidate features" were then used to perform penalized logistic regression analysis using poor outcome as the dependent variable. Penalized logistic regression models that maximized specificity for poor outcome were generated over several time periods and evaluated how sensitivities changed over time. RESULTS 16 patients with poor-grade SAH were evaluated. Average PRx trajectories for the good (PRx < 0.25) and poor outcome groups (PRx > 0.5) started diverging at post-ictus day 8. When targeting specificities ≥88% for poor outcome, sensitivities for poor outcome consistently increased to >70% starting at post-ictus days 12-14 with a maximum sensitivity of 75% occurring at day 18. CONCLUSIONS Our results suggest that by using PRx trends, early neuroprognostication in patients with SAH and poor clinical exams may start becoming apparent at post-ictus day 8 and reach adequate sensitivities by post-ictus days 12-14. Further study is required to validate this in larger poor-grade SAH populations.
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Affiliation(s)
- Jason J Chang
- Department of Critical Care Medicine, MedStar Washington Hospital Center, Washington, DC, USA; Department of Neurology, Georgetown University Medical Center, Washington, DC, USA.
| | - David Kepplinger
- Department of Statistics, George Mason University, Fairfax, VA, USA
| | - E Jeffrey Metter
- Department of Neurology, University of Tennessee Health Science Center, Memphis, TN, USA
| | - Daniel R Felbaum
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Jeffrey C Mai
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Rocco A Armonda
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
| | - Edward F Aulisi
- Department of Neurosurgery, Georgetown University and MedStar Washington Hospital Center, Washington, DC, USA
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14
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Svedung Wettervik T, Hånell A, Howells T, Ronne Engström E, Lewén A, Enblad P. ICP, CPP, and PRx in traumatic brain injury and aneurysmal subarachnoid hemorrhage: association of insult intensity and duration with clinical outcome. J Neurosurg 2023; 138:446-453. [PMID: 35901752 DOI: 10.3171/2022.5.jns22560] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2022] [Accepted: 05/05/2022] [Indexed: 02/04/2023]
Abstract
OBJECTIVE The primary aim of this study was to determine the combined effect of insult intensity and duration of intracranial pressure (ICP), cerebral perfusion pressure (CPP), and pressure reactivity index (PRx) on outcome measured with the Glasgow Outcome Scale-Extended (GOS-E) in patients with traumatic brain injury (TBI) or aneurysmal subarachnoid hemorrhage (aSAH). METHODS This observational study included all TBI and aSAH patients treated in the neurointensive care unit in Uppsala, Sweden, 2008-2018, with at least 24 hours of ICP monitoring during the first 10 days following injury and available long-term clinical outcome data. ICP, CPP, and PRx insults were visualized as 2D plots to highlight the effects of both insult intensity and duration on patient outcome. RESULTS Of 950 included patients, 436 were TBI and 514 aSAH patients. The TBI patients were younger, more often male, and exhibited worse neurological status at admission, but recovered more favorably than the aSAH patients. There was a transition from good to poor outcome with ICP above 15-20 mm Hg in both TBI and aSAH. The two diagnoses had opposite CPP patterns. In TBI patients, CPP episodes at or below 80 mm Hg were generally favorable, whereas CPP episodes above 80 mm Hg were favorable in the aSAH patients. In the TBI patients there was a transition from good to poor outcome when PRx exceeded zero, but no evident transition was found in the aSAH cohort. CONCLUSIONS The insult intensity and duration plots formulated in this study illustrate the similarities and differences between TBI and aSAH patients. In particular, aSAH patients may benefit from much higher CPP targets than TBI patients.
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Affiliation(s)
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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15
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Gathier CS, Zijlstra IJAJ, Rinkel GJE, Groenhof TKJ, Verbaan D, Coert BA, Müller MCA, van den Bergh WM, Slooter AJC, Eijkemans MJC. Blood pressure and the risk of rebleeding and delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage. J Crit Care 2022; 72:154124. [PMID: 36208555 DOI: 10.1016/j.jcrc.2022.154124] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/13/2022] [Revised: 07/04/2022] [Accepted: 07/29/2022] [Indexed: 11/27/2022]
Abstract
INTRODUCTION AND OBJECTIVE Blood pressure is presumably related to rebleeding and delayed cerebral ischemia (DCI) after subarachnoid hemorrhage (aSAH) and could serve as a target to improve outcome. We assessed the associations between blood pressure and rebleeding or DCI in aSAH-patients. MATERIALS AND METHODS In this observational study in 1167 aSAH-patients admitted to the intensive care unit (ICU), adjusted hazard ratio's (aHR) were calculated for the time-dependent association of blood pressure and rebleeding or DCI. The aHRs were presented graphically, relative to a reference mean arterial pressure (MAP) of 100 mmHg and systolic blood pressure (sBP) of 150 mmHg. RESULTS A MAP below 100 mmHg in the 6, 3 and 1 h before each moment in time was associated with a decreased risk of rebleeding (e.g. within 6 h preceding rebleeding: MAP = 80 mmHg: aHR 0.30 (95% confidence interval (CI) 0.11-0.80)). A MAP below 60 mmHg in the 24 h before each moment in time was associated with an increased risk of DCI (e.g. MAP = 50 mmHg: aHR 2.59 (95% CI 1.12-5.96)). CONCLUSIONS Our results suggest that a MAP below 100 mmHg is associated with decreased risk of rebleeding, and a MAP below 60 mmHg with increased risk of DCI.
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Affiliation(s)
- Celine S Gathier
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands.
| | - IJsbrand A J Zijlstra
- Department of Radiology, Amsterdam University Medical Center, location AMC, University of Amsterdam, Amsterdam, the Netherlands
| | - Gabriel J E Rinkel
- Department of Neurology and Neurosurgery and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands
| | - T Katrien J Groenhof
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
| | - Dagmar Verbaan
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Bert A Coert
- Neurosurgical Center Amsterdam, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Marcella C A Müller
- Department of Intensive Care, Amsterdam University Medical Center, location AMC, Amsterdam, the Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University Medical Center Groningen, University of Groningen, Groningen, the Netherlands
| | - Arjen J C Slooter
- Department of Intensive Care Medicine and UMC Utrecht Brain Center, University Medical Center Utrecht, Utrecht University, Utrecht, the Netherlands; Department of Neurology, UZ Brussel and Vrije Universiteit Brussel, Brussels, Belgium
| | - Marinus J C Eijkemans
- Julius Center for Health Sciences and Primary Care, University Medical Center Utrecht, Utrecht, the Netherlands
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16
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Svedung Wettervik T, Howells T, Hånell A, Nyberg C, Ronne-Engström E. NT-proBNP and troponin I in high-grade aneurysmal subarachnoid hemorrhage: Relation to clinical course and outcome. J Crit Care 2022; 72:154123. [PMID: 35908328 DOI: 10.1016/j.jcrc.2022.154123] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/23/2021] [Revised: 05/24/2022] [Accepted: 07/22/2022] [Indexed: 12/15/2022]
Abstract
PURPOSE To investigate the association between two cardiac biomarkers, NT-proBNP and TnI, with intracranial pressure (ICP)-/cerebral perfusion pressure (CPP)-insults, cerebral pressure autoregulation, delayed ischemic neurological deficits (DIND), and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). METHODS In this retrospective study, 196 aSAH patients treated at the neurointensive care unit, Uppsala University Hospital, Sweden, 2011-2018, with ICP-monitoring and serial NT-proBNP and TnI measurements were included. The first 10 days were divided into early phase (day 1-3) and vasospasm phase (day 4-10). RESULTS NT-proBNP and TnI were elevated above the reference interval at least once the first 10 days in 175 (89%) and 116 (59%) patients, respectively. In the vasospasm phase, higher NT-proBNP and TnI were associated with increased percentage of CPP below 60 mmHg. Higher TnI also correlated with more ICP-insults above 20 mmHg. NT-proBNP and TnI did not predict worse pressure autoregulation and DIND. Higher NT-proBNP and TnI were associated with mortality and unfavorable outcome in univariate, but not multivariate, analyses. CONCLUSION Elevated NT-proBNP and TnI correlated with an increased burden of secondary ICP-/CPP-insults, but not with worse pressure autoregulation, DIND, and without independent association with clinical outcome.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden.
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Anders Hånell
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Christoffer Nyberg
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85 Uppsala, Sweden
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Ota N, Noda K, Chida D, Kiko K, Miyoshi N, Kondo T, Haraguchi K, Kamiyama H, Tokuda S, Tanikawa R. Emergent Subarachnoid Clot Removal with Aneurysm Repair for Subarachnoid Hemorrhage Might Improves Clinical Outcome. World Neurosurg 2022; 167:e100-e109. [PMID: 35953044 DOI: 10.1016/j.wneu.2022.07.151] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/16/2022] [Accepted: 07/22/2022] [Indexed: 12/01/2022]
Abstract
BACKGROUND The goal in treating patients with subarachnoid hemorrhage (SAH) is shifting to preventing early brain injury. Intracranial pressure must be controlled to manage such an injury. We retrospectively analyzed the impact of aggressive removal of cisternal subarachnoid clots with simultaneous aneurysm repair for all grades of SAH. METHODS Our study included 260 consecutive patients with SAH treated through aggressive subarachnoid clot removal with simultaneous aneurysm repair. Baseline patient characteristics, history, radiographic findings, and time of SAH onset to arrival in the operating room were retrospectively collected. Factors related to poor outcome (modified Rankin Scale score >2) were analyzed. RESULTS Multivariate analysis revealed several characteristics were significantly associated with poor outcome: advanced age (adjusted odds ratio [aOR] 1.07, 95% confidence interval [CI] 1.04-01.10); time of SAH onset to operating room per 1-hour increments (aOR 1.03, 95% CI 1.01-01.05; postoperative hematoma volume (aOR 1.04, 95% CI 1.01-01.06); and poorer World Federation of Neurosurgical Societies grade (aOR 2.18, 95% CI 1.63-02.92). According to a receiver operating characteristic analysis, the cut-off time of SAH onset to operating room was 6.0 hours (area under the curve 0.61, P = 0.01, 95% CI 0.52-0.69, sensitivity = 0.79, specificity = 0.43) as the threshold between modified Rankin Scale scores of 0-2 and 3-6. CONCLUSIONS Prognostic factors of SAH in patients undergoing emergent aneurysm repair with simultaneous removal of a cisternal subarachnoid clot are advanced age, poorer World Federation of Neurosurgical Societies grade, postoperative hematoma volume, and a longer time from SAH onset to operating room. The clinical outcome may improve with emergent reduction of intracranial pressure through removal of the subarachnoid clot as soon as possible.
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Affiliation(s)
- Nakao Ota
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan.
| | - Kosumo Noda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Daiki Chida
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Katsunari Kiko
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Norio Miyoshi
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Tomomasa Kondo
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Kenichi Haraguchi
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Hiroyasu Kamiyama
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Sadahisa Tokuda
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
| | - Rokuya Tanikawa
- Stroke Center, Department of Neurosurgery, Sapporo Teishinkai Hospital, Sapporo, Hokkaido, Japan
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18
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Han H, Chen Y, Li R, Lin F, Lu J, Chen X, Wang S. The value of early CT perfusion parameters for predicting delayed cerebral ischemia after aneurysmal subarachnoid hemorrhage: a systematic review and meta-analysis. Neurosurg Rev 2022; 45:2517-2531. [PMID: 35377027 DOI: 10.1007/s10143-022-01779-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/28/2021] [Revised: 03/13/2022] [Accepted: 03/28/2022] [Indexed: 12/30/2022]
Abstract
Delayed cerebral ischemia (DCI) is a devastating complication of aneurysmal subarachnoid hemorrhage (aSAH). We aim to investigate the efficacy of early CT perfusion (CTP) parameters for predicting DCI in patients with aSAH. The search was conducted in five databases (PubMed, Embase, Cochrane Library, China National Knowledge Infrastructure, and China Biology Medicine database). Studies were reviewed by two independent authors, and the included studies were assessed for methodological quality. Fifteen studies with 882 participants were included for the final analysis. The meta-analysis of quantitative parameters showed that mean transit time represented the most valuable predictor when the calculation of the mean value was uniformed (MD 0.30 s, 95% CI: 0.10 to 0.49 s, P = 0.003). Semi-quantitative parameters using relative values or index scores were also widely used to minimize undue variations derived from patients, operators, machines, and software. Studies also demonstrated that these relative parameters had better predictive accuracy than corresponding absolute parameters. Perfusion thresholds in each study were incomparable, and the results warranted further validation. The best threshold for the prediction was 0.9 using the relative cerebral blood flow parameter (sensitivity 97% and specificity 89%). We conclude that CTP in the early phase is a promising tool for predicting DCI in aSAH patients. However, the parameters require standardization. Future studies with prospective, multi-centered design and large sample size are needed to validate the thresholds and optimize the parameters.
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Affiliation(s)
- Heze Han
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Yu Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Runting Li
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Fa Lin
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Junlin Lu
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China.,China National Clinical Research Center for Neurological Diseases, Beijing, China
| | - Xiaolin Chen
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
| | - Shuo Wang
- Department of Neurosurgery, Beijing Tiantan Hospital, Capital Medical University, Beijing, China. .,China National Clinical Research Center for Neurological Diseases, Beijing, China.
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19
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Owen B, Vangala A, Fritch C, Alsarah AA, Jones T, Davis H, Shuttleworth CW, Carlson AP. Cerebral Autoregulation Correlation With Outcomes and Spreading Depolarization in Aneurysmal Subarachnoid Hemorrhage. Stroke 2022; 53:1975-1983. [PMID: 35196873 PMCID: PMC9133018 DOI: 10.1161/strokeaha.121.037184] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
BACKGROUND Delayed cerebral ischemia remains one of the principal therapeutic targets after aneurysmal subarachnoid hemorrhage. While large vessel vasospasm may contribute to ischemia, increasing evidence suggests that physiological impairment through disrupted impaired cerebral autoregulation (CA) and spreading depolarizations (SDs) also contribute to delayed cerebral ischemia and poor neurological outcome. This study seeks to explore the intermeasure correlation of different measures of CA, as well as correlation with SD and neurological outcome. METHODS Simultaneous measurement of 7 continuous indices of CA was calculated in 19 subjects entered in a prospective study of SD in aneurysmal subarachnoid hemorrhage undergoing surgical aneurysm clipping. Intermeasure agreement was assessed, and the association of each index with modified Rankin Scale score at 90 days and occurrence of SD was assessed. RESULTS There were 4102 hours of total monitoring time across the 19 subjects. In time-resolved assessment, no CA measures demonstrated significant correlation; however, most demonstrate significant correlation averaged over 1 hour. Pressure reactivity (PRx), oxygen reactivity, and oxygen saturation reactivity were significantly correlated with modified Rankin Scale score at 90 days. PRx and oxygen reactivity also were correlated with the occurrence of SD events. Across multiple CA measure reactivity indices, a threshold between 0.3 and 0.5 was most associated with intervals containing SD. CONCLUSIONS Different continuous CA indices do not correlate well with each other on a highly time-resolved basis, so should not be viewed as interchangeable. PRx and oxygen reactivity are the most reliable indices in identifying risk of worse outcome in patients with aneurysmal subarachnoid hemorrhage undergoing surgical treatment. SD occurrence is correlated with impaired CA across multiple CA measurement techniques and may represent the pathological mechanism of delayed cerebral ischemia in patients with impaired CA. Optimization of CA in patients with aneurysmal subarachnoid hemorrhage may lead to decreased incidence of SD and improved neurological outcomes. Future studies are needed to evaluate these hypotheses and approaches.
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Affiliation(s)
- Bryce Owen
- University of New Mexico, School of Medicine
| | - Adarsh Vangala
- University of Arizona College of Medicine, Department of Internal Medicine
| | - Chanju Fritch
- Penn State School of Medicine, Department of Neurosurgery
| | - Ali A. Alsarah
- University of New Mexico School of Medicine, Department of Neurology
| | - Tom Jones
- University of New Mexico School of Medicine, Department of Psychiatry
| | - Herbert Davis
- University of New Mexico School of Medicine, Department of Internal Medicine, Division of Epidemiology, Biostatistics, and Preventive Medicine
| | | | - Andrew P. Carlson
- University of New Mexico School of Medicine, Department of Neurosurgery
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20
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Zimmerman WD, Chang WTW. ED BP Management for Subarachnoid Hemorrhage. Curr Hypertens Rep 2022; 24:303-309. [PMID: 35608789 DOI: 10.1007/s11906-022-01199-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 05/15/2022] [Indexed: 11/25/2022]
Abstract
PURPOSE OF REVIEW To review most recent literature on management of blood pressure in acute aneurysmal subarachnoid hemorrhage (SAH) and provide practice recommendations for the emergency clinician. RECENT FINDINGS There is increased risk of aneurysmal rebleeding with systolic blood pressure (SBP) greater than 160 mmHg in the acute setting. Avoiding large degrees of blood pressure variability improves clinical outcomes in aneurysmal SAH. Acute lowering of SBP to a range of 140-160 mmHg decreases risk of rebleeding while also maintaining cerebral perfusion pressure (CPP) after aneurysmal rupture. Treatment with a short acting antihypertensive agent allows for rapid titration of blood pressure (BP) and reduces BP variability. Elevations in intracranial pressure occur commonly after SAH due to increased intracranial blood volume, cerebral edema, or development of hydrocephalus. Clinicians should be familiar with changes in cerebral autoregulation and effects on CPP when treating elevated BP, in order to mitigate the risk of secondary neurological injury.
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Affiliation(s)
- W Denney Zimmerman
- Department of Neurology, University of Maryland Medical Center, Baltimore, MD, 21201, USA
| | - Wan-Tsu W Chang
- Departments of Emergency Medicine and Neurology, Program in Trauma, University of Maryland School of Medicine, 22 S. Greene St, Baltimore, MD, 21201, USA.
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21
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Al-Kawaz M, Cho SM, Gottesman RF, Suarez JI, Rivera-Lara L. Impact of Cerebral Autoregulation Monitoring in Cerebrovascular Disease: A Systematic Review. Neurocrit Care 2022; 36:1053-1070. [PMID: 35378665 DOI: 10.1007/s12028-022-01484-5] [Citation(s) in RCA: 15] [Impact Index Per Article: 7.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/29/2021] [Accepted: 03/01/2022] [Indexed: 12/16/2022]
Abstract
Cerebral autoregulation (CA) prevents brain injury by maintaining a relatively constant cerebral blood flow despite fluctuations in cerebral perfusion pressure. This process is disrupted consequent to various neurologic pathologic processes, which may result in worsening neurologic outcomes. Herein, we aim to highlight evidence describing CA changes and the impact of CA monitoring in patients with cerebrovascular disease, including ischemic stroke, intracerebral hemorrhage (ICH), and aneurysmal subarachnoid hemorrhage (aSAH). The study was preformed according to the Preferred Reporting Items for Systematic Reviews and Meta-Analysis guidelines. English language publications were identified through a systematic literature conducted in Ovid Medline, PubMed, and Embase databases. The search spanned the dates of each database's inception through January 2021. We selected case-control studies, cohort observational studies, and randomized clinical trials for adult patients (≥ 18 years) who were monitored with continuous metrics using transcranial Doppler, near-infrared spectroscopy, and intracranial pressure monitors. Of 2799 records screened, 48 studies met the inclusion criteria. There were 23 studies on ischemic stroke, 18 studies on aSAH, 5 studies on ICH, and 2 studies on systemic hypertension. CA impairment was reported after ischemic stroke but generally improved after tissue plasminogen activator administration and successful mechanical thrombectomy. Persistent impairment in CA was associated with hemorrhagic transformation, malignant cerebral edema, and need for hemicraniectomy. Studies that investigated large ICHs described bilateral CA impairment up to 12 days from the ictus, especially in the presence of small vessel disease. In aSAH, impairment of CA was associated with angiographic vasospasm, delayed cerebral ischemia, and poor functional outcomes at 6 months. This systematic review highlights the available evidence for CA disruption during cerebrovascular diseases and its possible association with long-term neurological outcome. CA may be disrupted even before acute stroke in patients with untreated chronic hypertension. Monitoring CA may help in establishing individualized management targets in patients with cerebrovascular disease.
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Affiliation(s)
- Mais Al-Kawaz
- Department of Neurosurgery, Icahn School of Medicine at Mount Sinai, New York, NY, USA.
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA.
| | - Sung-Min Cho
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Rebecca F Gottesman
- Stroke Branch, National Institute of Neurological Disorders and Stroke Intramural Program, National Institutes of Health, Bethesda, MD, USA
| | - Jose I Suarez
- Department of Neurology, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
- Department of Neurosurgery, The Johns Hopkins University School of Medicine, Baltimore, MD, USA
| | - Lucia Rivera-Lara
- Division of Stroke and Neurocritical Care, Stanford University, Palo Alto, CA, USA
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22
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Nogueira RC, Aries M, Minhas JS, H Petersen N, Xiong L, Kainerstorfer JM, Castro P. Review of studies on dynamic cerebral autoregulation in the acute phase of stroke and the relationship with clinical outcome. J Cereb Blood Flow Metab 2022; 42:430-453. [PMID: 34515547 PMCID: PMC8985432 DOI: 10.1177/0271678x211045222] [Citation(s) in RCA: 24] [Impact Index Per Article: 12.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/11/2023]
Abstract
Acute stroke is associated with high morbidity and mortality. In the last decades, new therapies have been investigated with the aim of improving clinical outcomes in the acute phase post stroke onset. However, despite such advances, a large number of patients do not demonstrate improvement, furthermore, some unfortunately deteriorate. Thus, there is a need for additional treatments targeted to the individual patient. A potential therapeutic target is interventions to optimize cerebral perfusion guided by cerebral hemodynamic parameters such as dynamic cerebral autoregulation (dCA). This narrative led to the development of the INFOMATAS (Identifying New targets FOr Management And Therapy in Acute Stroke) project, designed to foster interventions directed towards understanding and improving hemodynamic aspects of the cerebral circulation in acute cerebrovascular disease states. This comprehensive review aims to summarize relevant studies on assessing dCA in patients suffering acute ischemic stroke, intracerebral haemorrhage, and subarachnoid haemorrhage. The review will provide to the reader the most consistent findings, the inconsistent findings which still need to be explored further and discuss the main limitations of these studies. This will allow for the creation of a research agenda for the use of bedside dCA information for prognostication and targeted perfusion interventions.
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Affiliation(s)
- Ricardo C Nogueira
- Neurology Department, School of Medicine, Hospital das Clinicas, University of São Paulo, São Paulo, Brazil.,Department of Neurology, Hospital Nove de Julho, São Paulo, Brazil
| | - Marcel Aries
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center+, School for Mental Health and Neuroscience (MHeNS), Maastricht, The Netherlands
| | - Jatinder S Minhas
- Cerebral Haemodynamics in Ageing and Stroke Medicine (CHiASM) Research Group, Department of Cardiovascular Sciences, NIHR Leicester Biomedical Research Centre, Glenfield Hospital, Leicester, UK
| | - Nils H Petersen
- Department of Neurology, Yale University School of Medicine, New Haven, USA
| | - Li Xiong
- Department of Medicine & Therapeutics, The Chinese University of Hong Kong, Hong Kong, China
| | - Jana M Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, USA.,Neuroscience Institute, Carnegie Mellon University, Pittsburgh, USA
| | - Pedro Castro
- Department of Neurology, Faculty of Medicine of University of Porto, Centro Hospitalar Universitário de São João, Porto, Portugal
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23
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Optimal Cerebral Perfusion Pressure During Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage. Crit Care Med 2022; 50:183-191. [PMID: 35100191 DOI: 10.1097/ccm.0000000000005396] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/20/2022]
Abstract
OBJECTIVES The recommendation of induced hypertension for delayed cerebral ischemia treatment after aneurysmal subarachnoid hemorrhage has been challenged recently and ideal pressure targets are missing. A new concept advocates an individual cerebral perfusion pressure where cerebral autoregulation functions best to ensure optimal global perfusion. We characterized optimal cerebral perfusion pressure at time of delayed cerebral ischemia and tested the conformity of induced hypertension with this target value. DESIGN Retrospective analysis of prospectively collected data. SETTING University hospital neurocritical care unit. PATIENTS Thirty-nine aneurysmal subarachnoid hemorrhage patients with invasive neuromonitoring (20 with delayed cerebral ischemia, 19 without delayed cerebral ischemia). INTERVENTIONS Induced hypertension greater than 180 mm Hg systolic blood pressure. MEASUREMENTS AND MAIN RESULTS Changepoint analysis was used to calculate significant changes in cerebral perfusion pressure, optimal cerebral perfusion pressure, and the difference of cerebral perfusion pressure and optimal cerebral perfusion pressure 48 hours before delayed cerebral ischemia diagnosis. Optimal cerebral perfusion pressure increased 30 hours before the onset of delayed cerebral ischemia from 82.8 ± 12.5 to 86.3 ± 11.4 mm Hg (p < 0.05). Three hours before delayed cerebral ischemia, a changepoint was also found in the difference of cerebral perfusion pressure and optimal cerebral perfusion pressure (decrease from -0.2 ± 11.2 to -7.7 ± 7.6 mm Hg; p < 0.05) with a corresponding increase in pressure reactivity index (0.09 ± 0.33 to 0.19 ± 0.37; p < 0.05). Cerebral perfusion pressure at time of delayed cerebral ischemia was lower than in patients without delayed cerebral ischemia in a comparable time frame (cerebral perfusion pressure delayed cerebral ischemia 81.4 ± 8.3 mm Hg, no delayed cerebral ischemia 90.4 ± 10.5 mm Hg; p < 0.05). Inducing hypertension resulted in a cerebral perfusion pressure above optimal cerebral perfusion pressure (+12.4 ± 8.3 mm Hg; p < 0.0001). Treatment response (improvement of delayed cerebral ischemia: induced hypertension+ [n = 15] or progression of delayed cerebral ischemia: induced hypertension- [n = 5]) did not correlate to either absolute values of cerebral perfusion pressure or optimal cerebral perfusion pressure, nor the resulting difference (cerebral perfusion pressure [p = 0.69]; optimal cerebral perfusion pressure [p = 0.97]; and the difference of cerebral perfusion pressure and optimal cerebral perfusion pressure [p = 0.51]). CONCLUSIONS At the time of delayed cerebral ischemia occurrence, there is a significant discrepancy between cerebral perfusion pressure and optimal cerebral perfusion pressure with worsening of autoregulation, implying inadequate but identifiable individual perfusion. Standardized induction of hypertension resulted in cerebral perfusion pressures that exceeded individual optimal cerebral perfusion pressure in delayed cerebral ischemia patients. The potential benefit of individual blood pressure management guided by autoregulation-based optimal cerebral perfusion pressure should be explored in future intervention studies.
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24
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Alexopoulos G, Zhang J, Karampelas I, Khan M, Quadri N, Patel M, Patel N, Almajali M, Mattei TA, Kemp J, Coppens J, Mercier P. Applied forecasting for delayed cerebral ischemia prediction post subarachnoid hemorrhage: Methodological fallacies. INFORMATICS IN MEDICINE UNLOCKED 2022. [DOI: 10.1016/j.imu.2021.100817] [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] Open
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25
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Beucler N, Sellier A, Dagain A. Letter to the Editor. Individualized blood pressure targets in the postoperative care of patients with ICH. J Neurosurg 2022; 136:314-315. [PMID: 34560631 DOI: 10.3171/2021.4.jns211038] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/06/2022]
Affiliation(s)
- Nathan Beucler
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
- 2Ecole du Val-de-Grâce, French Military Health Service Academy, Paris, France
| | | | - Arnaud Dagain
- 1Sainte-Anne Military Teaching Hospital, Toulon, France
- 3Val-de-Grâce Military Academy, Paris, France
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26
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Rass V, Bogossian EG, Ianosi BA, Peluso L, Kofler M, Lindner A, Schiefecker AJ, Putnina L, Gaasch M, Hackl WO, Beer R, Pfausler B, Taccone FS, Helbok R. The effect of the volemic and cardiac status on brain oxygenation in patients with subarachnoid hemorrhage: a bi-center cohort study. Ann Intensive Care 2021; 11:176. [PMID: 34914011 PMCID: PMC8677880 DOI: 10.1186/s13613-021-00960-z] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/08/2021] [Accepted: 11/28/2021] [Indexed: 12/23/2022] Open
Abstract
Background Fluid management in patients after subarachnoid hemorrhage (SAH) aims at the optimization of cerebral blood flow and brain oxygenation. In this study, we investigated the effects of hemodynamic management on brain oxygenation by integrating advanced hemodynamic and invasive neuromonitoring. Methods This observational cohort bi-center study included data of consecutive poor-grade SAH patients who underwent pulse contour cardiac output (PiCCO) monitoring and invasive neuromonitoring. Fluid management was guided by the transpulmonary thermodilution system and aimed at euvolemia (cardiac index, CI ≥ 3.0 L/min/m2; global end-diastolic index, GEDI 680–800 mL/m2; stroke volume variation, SVV < 10%). Patients were managed using a brain tissue oxygenation (PbtO2) targeted protocol to prevent brain tissue hypoxia (BTH, PbtO2 < 20 mmHg). To assess the association between CI and PbtO2 and the effect of fluid challenges on CI and PbtO2, we used generalized estimating equations to account for repeated measurements. Results Among a total of 60 included patients (median age 56 [IQRs 47–65] years), BTH occurred in 23% of the monitoring time during the first 10 days since admission. Overall, mean CI was within normal ranges (ranging from 3.1 ± 1.3 on day 0 to 4.1 ± 1.1 L/min/m2 on day 4). Higher CI levels were associated with higher PbtO2 levels (Wald = 14.2; p < 0.001). Neither daily fluid input nor fluid balance was associated with absolute PbtO2 levels (p = 0.94 and p = 0.85, respectively) or the occurrence of BTH (p = 0.68 and p = 0.71, respectively). PbtO2 levels were not significantly different in preload dependent patients compared to episodes of euvolemia. PbtO2 increased as a response to fluid boluses only if BTH was present at baseline (from 13 ± 6 to 16 ± 11 mmHg, OR = 13.3 [95% CI 2.6–67.4], p = 0.002), but not when all boluses were considered (p = 0.154). Conclusions In this study a moderate association between increased cardiac output and brain oxygenation was observed. Fluid challenges may improve PbtO2 only in the presence of baseline BTH. Individualized hemodynamic management requires advanced cardiac and brain monitoring in critically ill SAH patients. Supplementary Information The online version contains supplementary material available at 10.1186/s13613-021-00960-z.
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Affiliation(s)
- Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
| | - Elisa Gouvea Bogossian
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Bogdan-Andrei Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.,Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Lorenzo Peluso
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Alois J Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Lauma Putnina
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Werner O Hackl
- Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Eduard Wallnoefer-Zentrum 1, 6060, Hall, Austria
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Fabio Silvio Taccone
- Department of Intensive Care, Erasme Hospital, Université Libre de Bruxelles, Route de Lennik, 808, 1070, Brussels, Belgium
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
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27
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Lindner A, Rass V, Ianosi BA, Schiefecker AJ, Kofler M, Gaasch M, Addis A, Rhomberg P, Pfausler B, Beer R, Schmutzhard E, Thomé C, Helbok R. Individualized blood pressure targets in the postoperative care of patients with intracerebral hemorrhage. J Neurosurg 2021; 135:1656-1665. [PMID: 33836501 DOI: 10.3171/2020.9.jns201024] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/31/2020] [Accepted: 09/14/2020] [Indexed: 11/06/2022]
Abstract
OBJECTIVE Recent guidelines recommend targeting a systolic blood pressure (SBP) < 140 mm Hg in the early management of patients with spontaneous intracerebral hemorrhage (ICH). The optimal SBP targets for ICH patients after hematoma evacuation (HE) remain unclear. Here, the authors aimed to define the optimal SBP range based on multimodal neuromonitoring data. METHODS Forty poor-grade ICH patients who had undergone HE and then monitoring of intracerebral pressure, brain tissue oxygen tension (PbtO2), and cerebral metabolism (via cerebral microdialysis [CMD]) were prospectively included. Episodes of brain tissue hypoxia (BTH) (1-hour averaged PbtO2 < 20 mm Hg) and metabolic distress (CMD-lactate/pyruvate ratio [LPR] ≥ 40) were identified and linked to corresponding parameters of hemodynamic monitoring (SBP and cerebral perfusion pressure [CPP]). Multivariable regression analysis was performed using generalized estimating equations to identify associations between SBP levels, PbtO2, and brain metabolism. RESULTS The mean patient age was 60 (range 51-66) years and the median [IQR] initial ICH volume was 47 [29-60] ml. In multivariable models adjusted for Glasgow Coma Scale score, probe location, ICH volume, and age, lower SBP was independently associated with a higher risk of BTH (≤ 120 mm Hg: adjusted OR 2.9, p = 0.007; 120-130 mm Hg: adj OR 2.4, p = 0.002; 130-140 mm Hg: adj OR 1.6, p = 0.017) compared to a reference range of 140-150 mm Hg at the level of the foramen interventriculare Monroi, which corresponded to a CPP of 70-80 mm Hg and SBP levels between 150 and 160 mm Hg at the heart level. After exclusion of episodes with mitochondrial dysfunction, SBP targets < 140 mm Hg were associated with higher odds of cerebral metabolic distress (≤ 130 mm Hg: OR 2.5, p = 0.041; 130-140 mm Hg: OR 2.3, p = 0.033). Patients with a modified Rankin Scale score ≥ 5 at neurological ICU discharge more often exhibited BTH than patients with better outcomes (51% vs 10%, p = 0.003). CONCLUSIONS These data suggest that lower SPB and CPP levels are associated with a higher risk for BTH. Further studies are needed to evaluate whether a higher SPB target may prevent BTH and improve outcomes.
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Affiliation(s)
- Anna Lindner
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Verena Rass
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Bogdan-Andrei Ianosi
- 1Neurological Intensive Care Unit, Department of Neurology, and
- 2Institute of Medical Informatics, UMIT: University for Health Sciences, Medical Informatics and Technology, Tyrol, Austria; and
| | | | - Mario Kofler
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Max Gaasch
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | - Alberto Addis
- 3School of Medicine and Surgery, University of Milano-Bicocca, Monza, Italy
| | | | | | - Ronny Beer
- 1Neurological Intensive Care Unit, Department of Neurology, and
| | | | | | - Raimund Helbok
- 1Neurological Intensive Care Unit, Department of Neurology, and
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28
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Svedung Wettervik T, Fahlström M, Enblad P, Lewén A. Cerebral Pressure Autoregulation in Brain Injury and Disorders-A Review on Monitoring, Management, and Future Directions. World Neurosurg 2021; 158:118-131. [PMID: 34775084 DOI: 10.1016/j.wneu.2021.11.027] [Citation(s) in RCA: 16] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/17/2021] [Revised: 11/03/2021] [Accepted: 11/05/2021] [Indexed: 12/14/2022]
Abstract
The role of cerebral pressure autoregulation (CPA) in brain injury and disorders has gained increased interest. The CPA is often disturbed as a consequence of acute brain injury, which contributes to further brain damage and worse outcome. Specifically, in severe traumatic brain injury, CPA disturbances predict worse clinical outcome and targeting an autoregulatory-oriented optimal cerebral perfusion pressure threshold may improve brain energy metabolism and clinical outcome. In aneurysmal subarachnoid hemorrhage, cerebral vasospasm in combination with distal autoregulatory disturbances precipitate delayed cerebral ischemia. The role of optimal cerebral perfusion pressure targets is less clear in aneurysmal subarachnoid hemorrhage, but high cerebral perfusion pressure targets are generally favorable in the vasospasm phase. In acute ischemia, autoregulatory disturbances may occur and autoregulatory-oriented blood pressure (optimal mean arterial pressure) management reduces the risk of hemorrhagic transformation, brain edema, and unfavorable outcome. In chronic occlusive disease such as moyamoya, the gradual reduction of the cerebral circulation leads to compensatory distal vasodilation and the residual CPA capacity predicts the risk for cerebral ischemia. In spontaneous intracerebral hemorrhage, the role of autoregulatory disturbances is less clear, but CPA disturbances correlate with worse clinical outcome. Also, in community-acquired bacterial meningitis, CPA dysfunction is frequent and correlates with worse clinical outcome, but autoregulatory management is yet to be evaluated. In this review, we discuss the role of CPA in different types of brain injury and disease, the strengths and limitations of the monitoring methods, the potentials of autoregulatory management, and future directions in the field.
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Affiliation(s)
| | - Markus Fahlström
- Department of Surgical Sciences, Section of Radiology, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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29
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Qin B, Xiang Y, Zheng J, Xu R, Guo Z, Cheng C, Jiang L, Wu Y, Sun X, Huang Z. Increase in Brain Volume After Aneurysmal Subarachnoid Hemorrhage Leads to Unfavorable Outcome: A Retrospective Study Quantified by CT Scan. Front Neurol 2021; 12:654419. [PMID: 34690905 PMCID: PMC8531099 DOI: 10.3389/fneur.2021.654419] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/18/2021] [Accepted: 08/17/2021] [Indexed: 01/19/2023] Open
Abstract
Background and Purpose: Primary brain swelling occurs in aneurysmal subarachnoid hemorrhage (aSAH) patients. The absence of a dynamic quantitative method restricts further study of primary brain swelling. This study compared differences in the change rate of brain volume (CRBV) between patients with and without primary brain swelling in the early stage of aSAH. Moreover, the relationship between CRBV and clinical outcomes was evaluated. Methods: Patients hospitalized within 24 h after aSAH were included in this retrospective study. Utilizing a qualitative standard established before the study to recognize primary brain swelling through brain CT after aSAH, clinical outcomes after 3 months of SAH were evaluated with a modified Rankin scale (mRS). The brain volume (BV) of each patient was calculated with a semiautomatic threshold algorithm of 3D-slicer, and the change in brain volume (CIBV) was obtained by subtracting the two extreme values (CIBV = BVmax – BVmin). The CRBV was obtained by CIBV/BVmin × 100%. The CRBV values that predicted unfavorable prognoses were estimated. Results: In total, 130 subjects were enrolled in the study. The mean CRBV in the non-swelling group and swelling group were 4.37% (±4.77) and 11.87% (±6.84), respectively (p < 0.05). CRBV was positively correlated with the length of hospital stay, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume (Spearman ρ = 0.334; p < 0.001; Pearson ρ = 0.269, p = 0.002; Pearson ρ = 0.278, p = 0.001; Pearson ρ = 0.233, p = 0.008, respectively). Analysis of variance showed significant differences in CIBV, CRBV, blood in the ambient cistern, blood in the lateral ventricle, and lateral ventricular volume among varying modified Fisher scale (mFisher), with higher admission mFisher scale, indicating larger values of these variables. After adjusting for risk factors, the model showed that for every 1% increase in the CRBV, the probability of poor clinical prognosis increased by a factor of 1.236 (95% CI = 1.056–1.446). In the stratified analysis, the odds of worse clinical outcomes increased with increases in the CRBV. Receiver operating characteristic curve analysis showed that HH grade, mFisher scale, and score of CRBV (SCRBV) had diagnostic performance for predicting unfavorable clinical outcomes. Conclusion: Primary brain swelling increases brain volume after aSAH. The CRBV quantified by 3D-Slicer can be used as a volumetric representation of the degree of brain swelling. A larger CRBV in the early stage of aSAH is associated with poor prognosis. The CRBV can be used as a neuroimaging biomarker of early brain injury after bleeding and may be an effective predictor of patients' clinical prognoses.
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Affiliation(s)
- Bin Qin
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China.,Department of Neurosurgery, The Second People's Hospital of Jiulongpo District, Chongqing, China
| | - Yi Xiang
- Department of Neurosurgery, Chongqing University Central Hospital, Chongqing, China
| | - Jianfeng Zheng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Rui Xu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zongduo Guo
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Chongjie Cheng
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Li Jiang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Yue Wu
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Xiaochuan Sun
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
| | - Zhijian Huang
- Department of Neurosurgery, The First Affiliated Hospital of Chongqing Medical University, Chongqing, China
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30
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Claassen JAHR, Thijssen DHJ, Panerai RB, Faraci FM. Regulation of cerebral blood flow in humans: physiology and clinical implications of autoregulation. Physiol Rev 2021; 101:1487-1559. [PMID: 33769101 PMCID: PMC8576366 DOI: 10.1152/physrev.00022.2020] [Citation(s) in RCA: 304] [Impact Index Per Article: 101.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023] Open
Abstract
Brain function critically depends on a close matching between metabolic demands, appropriate delivery of oxygen and nutrients, and removal of cellular waste. This matching requires continuous regulation of cerebral blood flow (CBF), which can be categorized into four broad topics: 1) autoregulation, which describes the response of the cerebrovasculature to changes in perfusion pressure; 2) vascular reactivity to vasoactive stimuli [including carbon dioxide (CO2)]; 3) neurovascular coupling (NVC), i.e., the CBF response to local changes in neural activity (often standardized cognitive stimuli in humans); and 4) endothelium-dependent responses. This review focuses primarily on autoregulation and its clinical implications. To place autoregulation in a more precise context, and to better understand integrated approaches in the cerebral circulation, we also briefly address reactivity to CO2 and NVC. In addition to our focus on effects of perfusion pressure (or blood pressure), we describe the impact of select stimuli on regulation of CBF (i.e., arterial blood gases, cerebral metabolism, neural mechanisms, and specific vascular cells), the interrelationships between these stimuli, and implications for regulation of CBF at the level of large arteries and the microcirculation. We review clinical implications of autoregulation in aging, hypertension, stroke, mild cognitive impairment, anesthesia, and dementias. Finally, we discuss autoregulation in the context of common daily physiological challenges, including changes in posture (e.g., orthostatic hypotension, syncope) and physical activity.
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Affiliation(s)
- Jurgen A H R Claassen
- Department of Geriatrics, Radboud University Medical Center, Donders Institute for Brain, Cognition, and Behaviour, Nijmegen, The Netherlands
| | - Dick H J Thijssen
- Department of Physiology, Radboud Institute for Health Sciences, Nijmegen, The Netherlands
- Research Institute for Sport and Exercise Sciences, Liverpool John Moores University, Liverpool, United Kingdom
| | - Ronney B Panerai
- Department of Cardiovascular Sciences, University of Leicester, Leicester, United Kingdom
- >National Institute for Health Research Leicester Biomedical Research Centre, University of Leicester, Leicester, United Kingdom
| | - Frank M Faraci
- Departments of Internal Medicine, Neuroscience, and Pharmacology, Carver College of Medicine, University of Iowa, Iowa City, Iowa
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31
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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32
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Svedung Wettervik T, Howells T, Lewén A, Ronne-Engström E, Enblad P. Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome. Neurocrit Care 2021; 34:390-402. [PMID: 33420669 PMCID: PMC8128752 DOI: 10.1007/s12028-020-01162-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/18/2020] [Indexed: 12/23/2022]
Abstract
BACKGROUND High intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome. METHODS In this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008-2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP-CPPopt) < - 10 mm Hg (%). RESULTS Of the 242 patients, 63 (26%) had favorable (GOS-E 5-8) and 179 (74%) had unfavorable (GOS-E 1-4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5-10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups. CONCLUSIONS Avoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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33
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Rass V, Helbok R. How to diagnose delayed cerebral ischaemia and symptomatic vasospasm and prevent cerebral infarction in patients with subarachnoid haemorrhage. Curr Opin Crit Care 2021; 27:103-114. [PMID: 33405414 DOI: 10.1097/mcc.0000000000000798] [Citation(s) in RCA: 32] [Impact Index Per Article: 10.7] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
PURPOSE OF REVIEW Delayed cerebral ischaemia (DCI) complicates the clinical course of patients with subarachnoid haemorrhage (SAH) in 20--30% and substantially worsens outcome. In this review, we describe a multimodal diagnostic approach based on underlying mechanisms of DCI and provide treatment options with a special focus on the most recently published literature. RECENT FINDINGS Symptomatic vasospasm refers to clinical deterioration in the presence of vasospasm whereas DCI constitutes multiple causes. Pathophysiologic mechanisms underlying DCI range beyond large vessel vasospasm from neuroinflammation, to microthromboembolism, impaired cerebral autoregulation, cortical spreading depolarizations and many others. The current definition of DCI can be challenged by these mechanisms. We propose a pragmatic approach using a combination of clinical examination, cerebral ultrasonography, neuroimaging modalities and multimodal neuromonitoring to trigger therapeutic interventions in the presence of DCI. In addition to prophylactic nimodipine and management principles to improve oxygen delivery and decrease the brain metabolic demand, other specific interventions include permissive hypertension, intra-arterial application of calcium channel blockers and in selected patients angioplasty. SUMMARY The complex pathophysiology underlying DCI urges for a multimodal diagnostic approach triggering targeted interventions. Novel treatment concepts still have to be proven in large trials.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse, Innsbruck, Austria
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34
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Cardiac Output and Cerebral Blood Flow: A Systematic Review of Cardio-Cerebral Coupling. J Neurosurg Anesthesiol 2021; 34:352-363. [PMID: 33782372 DOI: 10.1097/ana.0000000000000768] [Citation(s) in RCA: 7] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2020] [Accepted: 02/09/2021] [Indexed: 11/26/2022]
Abstract
Control of cerebral blood flow (CBF) is crucial to the management of neurocritically ill patients. Small studies which have examined the role of cardiac output (CO) as a determinant of CBF have inconsistently demonstrated evidence of cardio-cerebral coupling. Putative physiological mechanisms underpinning such coupling include changes in arterial blood pressure pulsatility, which would produce vasodilation through increased oscillatory wall-shear-stress and baroreceptor mediated reflex sympatholysis, and changes in venous backpressure which may improve cerebral perfusion pressure. We sought to summarize and contextualize the literature on the relationship between CO and CBF and discuss the implications of cardio-cerebral coupling for neurocritical care. A systematic review of the literature yielded 41 studies; all were of low-quality and at high-risk of bias. Results were heterogenous, with evidence for both corroboration and confutation of a relationship between CO and CBF in both normal and abnormal cerebrovascular states. Common limitations of studies were lack of instantaneous CBF measures with reliance on transcranial Doppler-derived blood flow velocity as a surrogate, inability to control for fluctuations in established determinants of CBF (eg, PaCO2), and direct effects on CBF by the interventions used to alter CO. Currently, the literature is insufficiently robust to confirm an independent relationship between CO and CBF. Hypothetically, the presence of cardio-cerebral coupling would have important implications for clinical practice. Manipulation of CBF could occur without the risks associated with extremes of arterial pressure, potentially improving therapy for those with cerebral ischemia of various etiologies. However, current literature is insufficiently robust to confirm an independent relationship between CO and CBF, and further studies with improved methodology are required before therapeutic interventions can be based on cardio-cerebral coupling.
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35
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Kramer AH. Critical ICP in Subarachnoid Hemorrhage: How High and How Long? Neurocrit Care 2021; 34:714-716. [PMID: 33655454 DOI: 10.1007/s12028-021-01205-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, ICU Administration, 3132 Hospital Drive NW, Calgary, AB , T2N 5A1, Canada.
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36
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The Importance of P btO 2 Probe Location for Data Interpretation in Patients with Intracerebral Hemorrhage. Neurocrit Care 2020; 34:804-813. [PMID: 32918157 PMCID: PMC8179893 DOI: 10.1007/s12028-020-01089-w] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/24/2020] [Accepted: 08/26/2020] [Indexed: 12/01/2022]
Abstract
Background/objective Monitoring of brain tissue oxygen tension (PbtO2) provides insight into brain pathophysiology after intracerebral hemorrhage (ICH). Integration of probe location is recommended to optimize data interpretation. So far, little is known about the importance of PbtO2 catheter location in ICH patients. Methods We prospectively included 40 ICH patients after hematoma evacuation (HE) who required PbtO2-monitoring. PbtO2-probe location was evaluated in all head computed tomography (CT) scans within the first 6 days after HE and defined as location in the healthy brain tissue or perilesional when the catheter tip was located within 1 cm of a focal lesion (hypodense or hyperdense). Generalized estimating equations were used to investigate levels of PbtO2 in relation to different probe locations. Results Patients were 60 [51–66] years old and had a median ICH-volume of 47 [29–60] mL. Neuromonitoring probes remained for a median of 6 [2–11] days. PbtO2-probes were located in healthy brain tissue in 18/40 (45%) patients and in perilesional brain tissue in 22/40 (55%) patients. In the acute phase after HE (0–72 h), PbtO2 levels were significantly lower (21 ± 12 mmHg vs. 29 ± 10 mmHg, p = 0.010) and brain tissue hypoxia (BTH) was more common in the perilesional area as compared to healthy brain tissue (46% vs. 19%, adjOR 4.0, 95% CI 1.54–10.58, p = 0.005). Episodes of BTH significantly decreased over time in patients with probes in perilesional location (p = 0.001) but remained stable in normal appearing area (p = 0.485). A significant association between BTH and poor functional outcome was only found when probes were located in the perilesional brain tissue (adjOR 6.6, 95% CI 1.3–33.8, p = 0.023). Conclusions In the acute phase, BTH was more common in the perilesional area compared to healthy brain tissue. The improvement of BTH in the perilesional area over time may be the result of targeted treatment interventions and tissue regeneration. Due to the localized measurement of invasive neuromonitoring devices, integration of probe location in the clinical management of ICH patients and in research protocols seems mandatory.
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37
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Early Transcranial Doppler Evaluation of Cerebral Autoregulation Independently Predicts Functional Outcome After Aneurysmal Subarachnoid Hemorrhage. Neurocrit Care 2020; 31:253-262. [PMID: 31102237 DOI: 10.1007/s12028-019-00732-5] [Citation(s) in RCA: 14] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/26/2022]
Abstract
BACKGROUND Cerebral autoregulation (CA) impairment after aneurysmal subarachnoid hemorrhage (SAH) has been associated with delayed cerebral ischemia and an unfavorable outcome. We investigated whether the early transient hyperemic response test (THRT), a transcranial Doppler (TCD)-based CA evaluation method, can predict functional outcome 6 months after aneurysmal SAH. METHODS This is a prospective observational study of all aneurysmal SAH patients consecutively admitted to a single center between January 2016 and February 2017. CA was evaluated within 72 h of hemorrhage by THRT, which describes the changes in cerebral blood flow velocity after a brief compression of the ipsilateral common carotid artery. CA was considered to be preserved when an increase ≥ 9% of baseline systolic velocity was present. According to the modified Rankin Scale (mRS: 4-6), the primary outcome was unfavorable 6 months after hemorrhage. Secondary outcomes included cerebral infarction, vasospasm on TCD, and an unfavorable outcome at hospital discharge. RESULTS Forty patients were included (mean age = 54 ± 12 years, 70% females). CA was impaired in 19 patients (47.5%) and preserved in 21 (52.5%). Impaired CA patients were older (59 ± 13 vs. 50 ± 9, p = 0.012), showed worse neurological conditions (Hunt&Hess 4 or 5-47.4% vs. 9.5%, p = 0.012), and clinical initial condition (APACHE II physiological score-12 [5.57-13] vs. 3.5 [3-5], p = 0.001). Fourteen patients in the impaired CA group and one patient in the preserved CA group progressed to an unfavorable outcome (73.7% vs. 4.7%, p = 0.0001). The impaired CA group more frequently developed cerebral infarction than the preserved CA group (36.8% vs. 0%, p = 0.003, respectively). After multivariate analysis, impaired CA (OR 5.15 95% CI 1.43-51.99, p = 0.033) and the APACHE II physiological score (OR 1.67, 95% CI 1.01-2.76, p = 0.046) were independently associated with an unfavorable outcome. CONCLUSIONS Early CA impairment detected by TCD and admission APACHE II physiological score independently predicted an unfavorable outcome after SAH.
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Gaasch M, Putzer G, Schiefecker AJ, Martini J, Strapazzon G, Ianosi B, Thome C, Paal P, Brugger H, Mair P, Helbok R. Cerebral Autoregulation Is Impaired During Deep Hypothermia—A Porcine Multimodal Neuromonitoring Study. Ther Hypothermia Temp Manag 2020; 10:122-127. [DOI: 10.1089/ther.2019.0009] [Citation(s) in RCA: 9] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/30/2022] Open
Affiliation(s)
- Max Gaasch
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Gabriel Putzer
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois J. Schiefecker
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Judith Martini
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Giacomo Strapazzon
- Institute of Mountain Emergency Medicine, European Academy (EURAC) Research, Bolzano, Italy
| | - Bogdan Ianosi
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Claudius Thome
- Department of Neurosurgery, Medical University of Innsbruck, Innsbruck, Austria
| | - Peter Paal
- Department of Anaesthesiology and Intensive Care Medicine, Hospital of the Brothers of St. John of God Salzburg, Salzburg, Austria
| | - Hermann Brugger
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Mountain Emergency Medicine, European Academy (EURAC) Research, Bolzano, Italy
| | - Peter Mair
- Department of Anesthesiology and Critical Care Medicine, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Neuro-Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Balbi M, Vega MJ, Lourbopoulos A, Terpolilli NA, Plesnila N. Long-term impairment of neurovascular coupling following experimental subarachnoid hemorrhage. J Cereb Blood Flow Metab 2020; 40:1193-1202. [PMID: 31296132 PMCID: PMC7238370 DOI: 10.1177/0271678x19863021] [Citation(s) in RCA: 19] [Impact Index Per Article: 4.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
CO2-reactivity and neurovascular coupling are sequentially lost within the first 24 h after subarachnoid hemorrhage (SAH). Whether and when these impairments recover is not known. Therefore, we investigated the reactivity of pial and intraparenchymal vessels by in vivo two-photon microscopy one month after experimental SAH. C57BL/6 mice were subjected to either sham surgery or SAH by filament perforation. One month later, cerebral blood flow following CO2-challenge and forepaw stimulation was assessed by laser Doppler fluxmetry. Diameters of pial and intraparenchymal arterioles were quantified by in vivo two-photon microscopy. One month after SAH, pial and parenchymal vessels dilated in response to CO2. Neurovascular coupling was almost completely absent after SAH: vessel diameter did not change upon forepaw stimulation compared to a 20% increase in sham-operated mice. The current results demonstrate that neurovascular function differentially recovers after SAH: while CO2-reactivity normalizes within one month after SAH, neurovascular coupling is still absent. These findings show an acute and persistent loss of neurovascular coupling after SAH that may serve as a link between early brain injury and delayed cerebral ischemia, two distinct pathophysiological phenomena after SAH that were so far believed not to be directly related.
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Affiliation(s)
- Matilde Balbi
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Graduate School of Systemic Neurosciences (GSN), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany
| | - Max Jativa Vega
- Graduate School of Systemic Neurosciences (GSN), Munich University Hospital, Munich, Germany
| | - Athanasios Lourbopoulos
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany
| | - Nicole A Terpolilli
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany.,Department of Neurosurgery, Munich University Hospital, Munich, Germany
| | - Nikolaus Plesnila
- Institute for Stroke and Dementia Research (ISD), Munich University Hospital, Munich, Germany.,Graduate School of Systemic Neurosciences (GSN), Munich University Hospital, Munich, Germany.,Munich Cluster of Systems Neurology (Synergy), Munich, Germany
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40
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Gunata M, Parlakpinar H, Acet H. Melatonin: A review of its potential functions and effects on neurological diseases. Rev Neurol (Paris) 2020; 176:148-165. [DOI: 10.1016/j.neurol.2019.07.025] [Citation(s) in RCA: 39] [Impact Index Per Article: 9.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/23/2019] [Revised: 07/03/2019] [Accepted: 07/16/2019] [Indexed: 12/12/2022]
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41
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Ianosi B, Rass V, Gaasch M, Huber L, Lindner A, Hackl WO, Kofler M, Schiefecker AJ, Almashad S, Beer R, Pfausler B, Helbok R. An Observational Study on the Use of Intravenous Non-Opioid Analgesics and Antipyretics in Poor-Grade Subarachnoid Hemorrhage: Effects on Hemodynamics and Systemic and Brain Temperature. Ther Hypothermia Temp Manag 2020; 10:27-36. [DOI: 10.1089/ther.2018.0046] [Citation(s) in RCA: 8] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/29/2022] Open
Affiliation(s)
- Bogdan Ianosi
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Institute of Medical Informatics, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall, Austria
| | - Verena Rass
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Max Gaasch
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Lukas Huber
- Institute of Medical Informatics, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall, Austria
| | - Anna Lindner
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Werner O. Hackl
- Institute of Medical Informatics, University for Health Sciences, Medical Informatics and Technology (UMIT), Hall, Austria
| | - Mario Kofler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Alois Josef Schiefecker
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Salma Almashad
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
- Faculty of Medicine, Alexandria University, Alexandria, Egypt
| | - Ronny Beer
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Bettina Pfausler
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
| | - Raimund Helbok
- Neurological Intensive Care Unit, Department of Neurology, Medical University of Innsbruck, Innsbruck, Austria
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Wolf S. Autoregulation Monitoring is Important: Even After Aneurysmal Subarachnoid Hemorrhage—Isn’t it? Neurocrit Care 2019; 31:245-246. [DOI: 10.1007/s12028-019-00778-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/26/2022]
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43
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Silverman A, Kodali S, Strander S, Gilmore EJ, Kimmel A, Wang A, Cord B, Falcone G, Hebert R, Matouk C, Sheth KN, Petersen NH. Deviation From Personalized Blood Pressure Targets Is Associated With Worse Outcome After Subarachnoid Hemorrhage. Stroke 2019; 50:2729-2737. [PMID: 31495332 PMCID: PMC6756936 DOI: 10.1161/strokeaha.119.026282] [Citation(s) in RCA: 27] [Impact Index Per Article: 5.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/09/2019] [Accepted: 07/31/2019] [Indexed: 11/16/2022]
Abstract
Background and Purpose- Optimal blood pressure (BP) management during the early stages of aneurysmal subarachnoid hemorrhage remains uncertain. Observational studies have found worse outcomes in patients with increased hemodynamic variability, suggesting BP optimization as a potential neuroprotective strategy. In this study, we calculated personalized BP targets at which cerebral autoregulation was best preserved. We analyzed how deviation from these limits correlates with functional outcome. Methods- We prospectively enrolled 31 patients with aneurysmal subarachnoid hemorrhage. Autoregulatory function was continuously measured by interrogating changes in near-infrared spectroscopy (NIRS)-derived tissue oxygenation-a surrogate for cerebral blood flow-as well as intracranial pressure (ICP) in response to changes in mean arterial pressure using time-correlation analysis. The resulting autoregulatory indices were used to identify the upper and lower limit of autoregulation. Percent time that mean arterial pressure exceeded limits of autoregulation was calculated for each patient. Functional outcome was assessed using the modified Rankin Scale at discharge and 90 days. Associations with outcome were analyzed using ordinal multivariate logistic regression. Results- Personalized limits of autoregulation were computed in all patients (age 57.5±13.4, 23F, mean World Federation of Neurological Surgeons 2±1, monitoring time 67.8±50.8 hours). Optimal BP and limits of autoregulation were calculated on average for 89.5±6.7% of the total monitoring period. ICP- and NIRS-derived optimal pressures strongly correlated with one another (P<0.0001). Percent time that mean arterial pressure deviated from limits of autoregulation significantly associated with worse functional outcome at discharge (NIRS, P=0.001; ICP, P=0.004) and 90 days (NIRS, P=0.002; ICP, P=0.003), adjusting separately for age, World Federation of Neurological Surgeons, vasospasm, and delayed cerebral ischemia. Conclusions- Both invasive (ICP) and noninvasive (NIRS) determination of personalized BP targets after aneurysmal subarachnoid hemorrhage is feasible, and these 2 approaches revealed significant collinearity. Furthermore, exceeding individualized limits of autoregulation was associated with poor functional outcomes.
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Affiliation(s)
| | - Sreeja Kodali
- Department of Neurology, Yale Medical School, New Haven, CT
| | | | | | | | - Anson Wang
- Department of Neurology, Yale Medical School, New Haven, CT
| | - Branden Cord
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Guido Falcone
- Department of Neurology, Yale Medical School, New Haven, CT
| | - Ryan Hebert
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Charles Matouk
- Department of Neurosurgery, Yale Medical School, New Haven, CT
| | - Kevin N. Sheth
- Department of Neurology, Yale Medical School, New Haven, CT
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Abstract
PURPOSE OF REVIEW Over the last years, the focus of clinical and animal research in subarachnoid hemorrhage (SAH) shifted towards the early phase after the bleeding based on the association of the early injury pattern (first 72 h) with secondary complications and poor outcome. This phase is commonly referenced as early brain injury (EBI). In this clinical review, we intended to overview commonly used definitions of EBI, underlying mechanisms, and potential treatment implications. RECENT FINDINGS We found a large heterogeneity in the definition used for EBI comprising clinical symptoms, neuroimaging parameters, and advanced neuromonitoring techniques. Although specific treatments are currently not available, therapeutic interventions are aimed at ameliorating EBI by improving the energy/supply mismatch in the early phase after SAH. Future research integrating brain-derived biomarkers is warranted to improve our pathophysiologic understanding of EBI in order to ameliorate early injury patterns and improve patients' outcomes.
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Affiliation(s)
- Verena Rass
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria
| | - Raimund Helbok
- Department of Neurology, Medical University of Innsbruck, Anichstrasse 35, 6020, Innsbruck, Austria.
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45
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Yu Z, Zheng J, Ma L, Li H, You C, Jiang Y. Predictive Value of Cerebral Autoregulation Impairment for Delayed Cerebral Ischemia in Aneurysmal Subarachnoid Hemorrhage: A Meta-Analysis. World Neurosurg 2019; 126:e853-e859. [PMID: 30862594 DOI: 10.1016/j.wneu.2019.02.188] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/07/2019] [Revised: 02/18/2019] [Accepted: 02/19/2019] [Indexed: 02/05/2023]
Abstract
OBJECTIVE Delayed cerebral ischemia (DCI) happens in about 30% of patients with aneurysmal subarachnoid hemorrhage (SAH) and is related to higher mortality and disability. Some studies have shown cerebral autoregulation impairment can be a predictor of DCI in aneurysmal SAH. We conducted this meta-analysis to evaluate the predictive value of cerebral autoregulation impairment for DCI based on the current literature. METHODS A systematic literature search was performed in PubMed and Embase. According to inclusion and exclusion criteria, 2 authors screened the records and extracted data from the included studies. Pooled sensitivity, specificity, and their 95% confidence intervals (CIs) were obtained. To investigate the overall accuracy, a summary receiver operating characteristic (SROC) curve was built and the area under SROC curve was calculated. Deeks' linear regression was used to assess the publication bias. All statistical analyses were performed with Stata 14.0. RESULTS A total of 7 studies were finally included in this meta-analysis. The pooled sensitivity and specificity values of impaired cerebral autoregulation for DCI prediction were 0.79 (95% CI, 0.65-0.88) and 0.85 (95% CI, 0.615-0.96). Moreover, the area under the SROC curve of cerebral autoregulation impairment for DCI prediction was 0.87 (95% CI, 0.835-0.89). No obvious publication bias was found in Deeks' linear regression (P = 0.99). CONCLUSIONS Cerebral autoregulation impairment can be a helpful predictor of DCI in aneurysmal SAH. Its accuracy for DCI prediction should be verified by more studies in the future.
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Affiliation(s)
- Zhiyuan Yu
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Jun Zheng
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Lu Ma
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Hao Li
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Chao You
- Department of Neurosurgery, West China Hospital, Sichuan University, Chengdu, Sichuan, China
| | - Yan Jiang
- Department of Nursing, West China Hospital, Sichuan University, Chengdu, Sichuan, China.
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Guo ZN, Jin H, Sun H, Zhao Y, Liu J, Ma H, Sun X, Yang Y. Antioxidant Melatonin: Potential Functions in Improving Cerebral Autoregulation After Subarachnoid Hemorrhage. Front Physiol 2018; 9:1146. [PMID: 30174621 PMCID: PMC6108098 DOI: 10.3389/fphys.2018.01146] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/25/2018] [Accepted: 07/30/2018] [Indexed: 12/30/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a subtype of stroke with high mortality and morbidity. Impaired cerebral autoregulation following SAH has been reported owing to effects on sympathetic control, endothelial function, myogenic response, and cerebral metabolism. Impaired cerebral autoregulation is associated with early brain injury, cerebral vasospasm/delayed cerebral ischemia, and SAH prognosis. However, few drugs have been reported to improve cerebral autoregulation after SAH. Melatonin is a powerful antioxidant that is effective (easily crosses the blood brain barrier) and safe (tolerated in large doses without toxicity). Theoretically, melatonin may impact the control mechanisms of cerebral autoregulation via antioxidative effects, protection of endothelial cell integrity, suppression of sympathetic nerve activity, increase in nitric oxide bioavailability, mediation of the myogenic response, and amelioration of hypoxemia. Furthermore, melatonin may have a comprehensive effect on cerebral autoregulation. This review discusses the potential effects of melatonin on cerebral autoregulation following SAH, in terms of the association between pharmacological activities and the mechanisms of cerebral autoregulation.
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Affiliation(s)
- Zhen-Ni Guo
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Hang Jin
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Huijie Sun
- Cadre Ward, The First Hospital of Jilin University, Changchun, China
| | - Yingkai Zhao
- Cadre Ward, The First Hospital of Jilin University, Changchun, China
| | - Jia Liu
- Shenzhen Institutes of Advanced Technology, Chinese Academy of Sciences, Shenzhen, China
| | - Hongyin Ma
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Xin Sun
- Department of Neurology, The First Hospital of Jilin University, Changchun, China
| | - Yi Yang
- Department of Neurology, The First Hospital of Jilin University, Changchun, China.,Clinical Trial and Research Center for Stroke, Department of Neurology, The First Hospital of Jilin University, Changchun, China
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