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Yang S, Tan B, Lin J, Wang X, Fu C, Wang K, Qian J, Liu J, Xian J, Tan L, Feng H, Chen Y, Wang L. Monitoring of Perioperative Microcirculation Dysfunction by Near-Infrared Spectroscopy for Neurological Deterioration and Prognosis of Aneurysmal Subarachnoid Hemorrhage: An Observational, Longitudinal Cohort Study. Neurol Ther 2024; 13:475-495. [PMID: 38367176 PMCID: PMC10951157 DOI: 10.1007/s40120-024-00585-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/28/2023] [Accepted: 01/25/2024] [Indexed: 02/19/2024] Open
Abstract
INTRODUCTION No evidence has established a direct causal relationship between early microcirculation disturbance after aneurysmal subarachnoid hemorrhage (aSAH) and neurological function prognosis, which is the key pathophysiological mechanism of early brain injury (EBI) in patients with aSAH. METHODS A total of 252 patients with aSAH were enrolled in the Neurosurgical Intensive Care Unit of Southwest Hospital between January 2020 and December 2022 and divided into the no neurological deterioration, early neurological deterioration, and delayed neurological deterioration groups. Indicators of microcirculation disorders in EBI included regional cerebral oxygen saturation (rSO2) measured by near-infrared spectroscopy (NIRS), brain oxygen monitoring, and other clinical parameters for evaluating neurological function and determining the prognosis of patients with aSAH. RESULTS Our data suggest that the rSO2 is generally lower in patients who develop neurological deterioration than in those who do not and that there is at least one time point in the population of patients who develop neurological deterioration where left and right cerebral hemisphere differences can be significantly monitored by NIRS. An unordered multiple-classification logistic regression model was constructed, and the results revealed that multiple factors were effective predictors of early neurological deterioration: reoperation, history of brain surgery, World Federation of Neurosurgical Societies (WFNS) grade 4-5, Fisher grade 3-4, SAFIRE grade 3-5, abnormal serum sodium and potassium levels, and reduced rSO2 during the perioperative period. However, for delayed neurological deterioration in patients with aSAH, only a history of brain surgery and perioperative RBC count were predictive indicators. CONCLUSIONS The rSO2 concentration in patients with neurological deterioration is generally lower than that in patients without neurological deterioration, and at least one time point in the population with neurological deterioration can be significantly monitored via NIRS. However, further studies are needed to determine the role of microcirculation and other predictive factors in the neurocritical management of EBI after aSAH, as these factors can reduce the incidence of adverse outcomes and mortality during hospitalization.
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Affiliation(s)
- Shunyan Yang
- School of Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou Province, China
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Binbin Tan
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jie Lin
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Department of Neurosurgery, The 943 Hospital of Joint Logistics Support Force of PLA, Wuwei, 733099, Gansu Province, China
| | - Xia Wang
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Congying Fu
- School of Nursing, Guizhou University of Traditional Chinese Medicine, Guiyang, 550025, Guizhou Province, China
| | - Kaishan Wang
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jinyu Qian
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jin Liu
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Jishu Xian
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Liang Tan
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Hua Feng
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China
| | - Yujie Chen
- Neurosurgical Intensive Care Unit, Department of Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China.
- Chongqing Clinical Research Center for Neurosurgery, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
- Chongqing Key Laboratory of Precision Neuromedicine and Neuroregenaration, Southwest Hospital, Third Military Medical University (Army Medical University), Chongqing, 400038, China.
| | - Lihua Wang
- Hospital Administration Office, Southwest Hospital, Third Military Medical University (Army Medical University), 29 Gaotanyan Street, Shapingba District, Chongqing, 400038, China.
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van der Harst JJ, Elting JWJ, Bokkers RPH, Veeger NJGM, van Donkelaar CE, van den Bergh WM, Metzemaekers JDM, Groen RJM, Mazuri A, Luijckx GJR, van Dijk JMC, Uyttenboogaart M. The Diagnostic Value of Near-Infrared Spectroscopy to Predict Delayed Cerebral Ischemia and Unfavorable Outcome After Subarachnoid Hemorrhage. World Neurosurg 2023; 178:e202-e212. [PMID: 37454906 DOI: 10.1016/j.wneu.2023.07.033] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/24/2023] [Accepted: 07/07/2023] [Indexed: 07/18/2023]
Abstract
OBJECTIVE Near-infrared spectroscopy (NIRS) is a noninvasive tool to monitor cerebral regional oxygen saturation. Impairment of microvascular circulation with subsequent cerebral hypoxia during delayed cerebral ischemia (DCI) is associated with poor functional outcome after subarachnoid hemorrhage (SAH). Therefore, NIRS could be useful to predict the risk for DCI and functional outcome. However, only limited data are available on NIRS regional cerebral tissue oxygen saturation (rSO2) distribution in SAH. The aim of this study was to compare the distribution of NIRS rSO2 values in patients with nontraumatic SAH with the occurrence of DCI and functional outcome at 2 months. In addition, the predictive value of NIRS rSO2 was compared with the previously validated SAFIRE grade (derived from Size of the aneurysm, Age, FIsher grade, World Federation of Neurosurgical Societies after REsuscitation). METHODS In this study, the rSO2 distribution of patients with and without DCI after SAH was compared. The optimal cutoff points to predict DCI and outcome were assessed, and its predictive value was compared with the SAFIRE grade. RESULTS Of 41 patients, 12 developed DCI, and 9 had unfavorable outcome at 60 days. Prediction of DCI with NIRS had an area under the curve of 0.77 (95% confidence interval 0.62-0.92; P = 0.0028) with an optimal cutoff point of 65% (sensitivity 1.00; specificity 0.45). Prediction of favorable outcome with NIRS had an area under the curve of 0.86 (95% confidence interval 0.74-0.98; P = 0.0003) with an optimal cutoff point of 63% (sensitivity 1.00; specificity 0.63). Regression analysis showed that NIRS rSO2 score is complementary to the SAFIRE grade. CONCLUSIONS NIRS rSO2 monitoring in patients with SAH may improve prediction of DCI and clinical outcome after SAH.
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Affiliation(s)
- J Joep van der Harst
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.
| | - Jan Willem J Elting
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Carlina E van Donkelaar
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan D M Metzemaekers
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aryan Mazuri
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gert-Jan R Luijckx
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands; Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Fan TH, Rosenthal ES. Physiological Monitoring in Patients with Acute Brain Injury: A Multimodal Approach. Crit Care Clin 2023; 39:221-233. [PMID: 36333033 DOI: 10.1016/j.ccc.2022.06.006] [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] [Indexed: 11/30/2022]
Abstract
Neurocritical care management of acute brain injury (ABI) is focused on identification, prevention, and management of secondary brain injury (SBI). Physiologic monitoring of the brain and other organ systems has a role to predict patient recovery or deterioration, guide individualized therapeutic interventions, and measure response to treatment, with the goal of improving patient outcomes. In this review, we detail how specific physiologic markers of brain injury and neuromonitoring tools are integrated and used in ABI patients to develop therapeutic approaches to prevent SBI.
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Affiliation(s)
- Tracey H Fan
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA; Department of Neurology, Division of Neurocritical Care, Brigham and Women's Hospital, 55 Fruit Street, Boston, MA 02493, USA
| | - Eric S Rosenthal
- Department of Neurology, Division of Neurocritical Care, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA; Department of Neurology, Division of Clinical Neurophysiology, Massachusetts General Hospital, 55 Fruit Street, Boston, MA 02493, USA.
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Sangeetha R, Ramesh V, Kamath S, Chakrabarti D, Christopher R, Aravinda H, Bhat D. Effect of remote ischemic preconditioning on cerebral oxygen saturation in aneurysmal subarachnoid hemorrhage: Secondary analysis of a randomized controlled trial. J Clin Neurosci 2022; 98:78-82. [DOI: 10.1016/j.jocn.2022.01.035] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/14/2021] [Revised: 01/07/2022] [Accepted: 01/24/2022] [Indexed: 11/16/2022]
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Chua MMJ, Enríquez-Marulanda A, Gomez-Paz S, Akamatsu Y, Salem MM, Maragkos GA, Ascanio LC, Hanafy KA, Fehnel CR, Ogilvy CS, Moore J, Thomas AJ. Sodium Variability and Probability of Vasospasm in Patients with Aneurysmal Subarachnoid Hemorrhage. J Stroke Cerebrovasc Dis 2021; 31:106186. [PMID: 34749298 DOI: 10.1016/j.jstrokecerebrovasdis.2021.106186] [Citation(s) in RCA: 6] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/11/2021] [Revised: 10/11/2021] [Accepted: 10/13/2021] [Indexed: 11/19/2022] Open
Abstract
OBJECTIVES Vasospasm is a well-known complication of aneurysmal subarachnoid hemorrhage (aSAH) that generally occurs 4-14 days post-hemorrhage. Based on American Heart Association guidelines, the current understanding is that hyponatremic episodes may lead to vasospasm. Therefore, we sought to determine the association between repeated serum sodium levels of aSAH patients and its relationship to radiographic vasospasm. MATERIALS AND METHODS A single-center retrospective analysis from 2007-2016 was conducted of aSAH patients. Daily serum sodium levels were recorded up to day 14 post-admission. Hyponatremia was defined as a serum sodium value of < 135 mEq/L. We evaluated the relationship to radiologic vasospasm, neurologic deterioration, functional status at discharge, and mortality. A repeated measures analysis using a mixed-effect regression model was performed to assess the interindividual relationship between serum sodium trends and outcomes. RESULTS A total of 296 aSAH patients were included. There were no significant differences in interindividual serum sodium values over time and occurrence of radiographic vasospasm, neurologic deterioration, functional, or mortality outcomes (p = .59, p = .42, p = .94, p = .99, respectively) using the mixed-effect regression model. However, overall mean serum sodium levels were significantly higher in patients who had neurologic deterioration, poor functional outcome (mRS 3-6), and mortality. CONCLUSIONS Serum sodium level variations are not associated with subsequent development of cerebral vasospasm in aSAH patients. These findings indicate that serum sodium may not have an impact on vasospasm, and avoiding hypernatremia may provide a neurologic, functional and survival benefit.
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Affiliation(s)
- Melissa M J Chua
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Brigham and Women's Hospital, Harvard Medical School, 60 Fenwood Road, BTM 4th floor, Boston, MA 02215, United States.
| | - Alejandro Enríquez-Marulanda
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Santiago Gomez-Paz
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Yosuke Akamatsu
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Mohamed M Salem
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Georgios A Maragkos
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States.
| | - Luis C Ascanio
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States; Department of Neurosurgery, Mount Sinai Hospital, New York, NY, United States.
| | - Khalid A Hanafy
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Corey R Fehnel
- Department of Neurology, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Christopher S Ogilvy
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Justin Moore
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
| | - Ajith J Thomas
- Division of Neurosurgery, Beth Israel Deaconess Medical Center, Harvard Medical School, Boston, MA, United States.
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van der Harst JJ, Luijckx GJR, Elting JWJ, Lammers T, Bokkers RPH, van den Bergh WM, Eshghi OS, Metzemaekers JDM, Groen RJM, Mazuri A, Veeger NJGM, van Dijk JMC, Uyttenboogaart M. The predictive value of the CTA Vasospasm Score on delayed cerebral ischaemia and functional outcome after aneurysmal subarachnoid hemorrhage. Eur J Neurol 2021; 29:620-625. [PMID: 34644440 PMCID: PMC9298005 DOI: 10.1111/ene.15139] [Citation(s) in RCA: 5] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2021] [Accepted: 10/09/2021] [Indexed: 11/30/2022]
Abstract
Background and purpose Delayed cerebral ischaemia (DCI) is a severe complication of aneurysmal subarachnoid hemorrhage that can significantly impact clinical outcome. Cerebral vasospasm is part of the pathophysiology of DCI and therefore a computed tomography angiography (CTA) Vasospasm Score was developed and an exploration was carried out of whether this score predicts DCI and subsequent poor outcome after aneurysmal subarachnoid hemorrhage. Methods The CTA Vasospasm Score sums the degree of angiographic cerebral vasospasm of 17 intradural arterial segments. The score ranges from 0 to 34 with a higher score reflecting more severe vasospasm. Outcome measures were cerebral infarction due to DCI (CI‐DCI), radiological and clinical DCI, and unfavorable functional outcome defined as a modified Rankin Scale >2 at 6 months. Receiver operating characteristic analyses were used to assess predictive value and to determine optimal cut‐off scores. Inter‐rater reliability was evaluated by Cohen's kappa coefficient. Results This study included 59 patients. CI‐DCI occurred in eight patients (14%), DCI in 14 patients (24%) and unfavorable outcome in 12 patients (20%). Median CTA Vasospasm Scores were higher in patients with (CI‐)DCI and poor outcome. Receiver operating characteristic analysis revealed the highest area under the curve on day 5: CI‐DCI 0.89 (95% confidence interval [CI] 0.79–0.99), DCI 0.68 (95% CI 0.50–0.87) and functional outcome 0.74 (95% CI 0.57–0.91). Cohen's kappa between the two raters was moderate to substantial (0.57–0.63). Conclusions This study demonstrates that the CTA Vasospasm Score on day 5 can reliably identify patients with a high risk of developing (CI‐)DCI and unfavorable outcome.
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Affiliation(s)
- J Joep van der Harst
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Gert-Jan R Luijckx
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan Willem J Elting
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Thijs Lammers
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Reinoud P H Bokkers
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Walter M van den Bergh
- Department of Critical Care, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Omid S Eshghi
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Jan D M Metzemaekers
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Rob J M Groen
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Aryan Mazuri
- Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Nic J G M Veeger
- Department of Epidemiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - J Marc C van Dijk
- Department of Neurosurgery, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
| | - Maarten Uyttenboogaart
- Department of Neurology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands.,Department of Radiology, University of Groningen, University Medical Center Groningen, Groningen, The Netherlands
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Bader ER, Allam MM, Harris TGW, Suchdev N, Loke YK, Barlas R. Thrombolysis for aneurysmal subarachnoid haemorrhage. Hippokratia 2020. [DOI: 10.1002/14651858.cd013748] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Edward R Bader
- Department of Neurological Surgery; Albert Einstein College of Medicine, Montefiore Medical Center; New York USA
| | - Mazen M Allam
- Foundation Programme; NHS Ayrshire and Arran; Kilmarnock UK
| | - Thomas G W Harris
- Department of Plastic and Reconstructive Surgery; Johns Hopkins University School of Medicine; Baltimore Maryland USA
| | - Neena Suchdev
- Foundation Programme; Freeman Hospital, The Newcastle upon Tyne Hospitals NHS Foundation Trust; Newcastle upon Tyne UK
| | - Yoon Kong Loke
- Norwich Medical School; University of East Anglia; Norwich UK
| | - Raphae Barlas
- Ageing Clinical and Experimental Research; University of Aberdeen; Aberdeen UK
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Machine Learning and Artificial Intelligence in Neurocritical Care: a Specialty-Wide Disruptive Transformation or a Strategy for Success. Curr Neurol Neurosci Rep 2019; 19:89. [PMID: 31720867 DOI: 10.1007/s11910-019-0998-8] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/30/2023]
Abstract
PURPOSE OF REVIEW Neurocritical care combines the complexity of both medical and surgical disease states with the inherent limitations of assessing patients with neurologic injury. Artificial intelligence (AI) has garnered interest in the basic management of these complicated patients as data collection becomes increasingly automated. RECENT FINDINGS In this opinion article, we highlight the potential AI has in aiding the clinician in several aspects of neurocritical care, particularly in monitoring and managing intracranial pressure, seizures, hemodynamics, and ventilation. The model-based method and data-driven method are currently the two major AI methods for analyzing critical care data. Both are able to analyze the vast quantities of patient data that are accumulated in the neurocritical care unit. AI has the potential to reduce healthcare costs, minimize delays in patient management, and reduce medical errors. However, these systems are an aid to, not a replacement for, the clinician's judgment.
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Al-Mufti F, Dodson V, Lee J, Wajswol E, Gandhi C, Scurlock C, Cole C, Lee K, Mayer SA. Artificial intelligence in neurocritical care. J Neurol Sci 2019; 404:1-4. [PMID: 31302258 DOI: 10.1016/j.jns.2019.06.024] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/28/2019] [Revised: 06/16/2019] [Accepted: 06/22/2019] [Indexed: 01/31/2023]
Abstract
BACKGROUND Neurocritical care combines the management of extremely complex disease states with the inherent limitations of clinically assessing patients with brain injury. As the management of neurocritical care patients can be immensely complicated, the automation of data-collection and basic management by artificial intelligence systems have garnered interest. METHODS In this opinion article, we highlight the potential artificial intelligence has in monitoring and managing several aspects of neurocritical care, specifically intracranial pressure, seizure monitoring, blood pressure, and ventilation. RESULTS The two major AI methods of analytical technique currently exist for analyzing critical care data: the model-based method and data driven method. Both of these methods have demonstrated an ability to analyze vast quantities of patient data, and we highlight the ways in which these modalities of artificial intelligence might one day play a role in neurocritical care. CONCLUSIONS While none of these artificial intelligence systems are meant to replace the clinician's judgment, these systems have the potential to reduce healthcare costs and errors or delays in medical management.
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Affiliation(s)
- Fawaz Al-Mufti
- Departments of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America; Departments of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America.
| | - Vincent Dodson
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America
| | - James Lee
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America; Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Ethan Wajswol
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America
| | - Chirag Gandhi
- Departments of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America; Departments of Neurology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America
| | - Corey Scurlock
- Departments of Anesthesiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America; Departments of Internal Medicine, Westchester Medical Center at New York Medical College, Valhalla, NY, United States of America
| | - Chad Cole
- Departments of Neurosurgery, Westchester Medical Center, New York Medical College, Valhalla, NY, United States of America
| | - Kiwon Lee
- Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, United States of America; Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, United States of America
| | - Stephan A Mayer
- Department of Neurology, Henry Ford Health System, Detroit, MI, United States of America
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Montrief T, Alerhand S, Jewell C, Scott J. Incorporation of Transcranial Doppler into the ED for the neurocritical care patient. Am J Emerg Med 2019; 37:1144-1152. [PMID: 30894296 DOI: 10.1016/j.ajem.2019.03.003] [Citation(s) in RCA: 11] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/18/2018] [Revised: 02/05/2019] [Accepted: 03/04/2019] [Indexed: 01/03/2023] Open
Abstract
INTRODUCTION In the catastrophic neurologic emergency, a complete neurological exam is not always possible or feasible given the time-sensitive nature of the underlying disease process, or if emergent airway management is indicated. As the neurologic exam may be limited in some patients, the emergency physician is reliant on the assessment of brainstem structures to determine neurological function. Physicians thus routinely depend on advanced imaging modalities to further investigate for potential catastrophic diagnoses. Acquiring these tests introduces the risks of transport as well as delays in managing time-sensitive neurologic processes. A more immediate, non-invasive bedside approach complementing these modalities has evolved: Transcranial Doppler (TCD). OBJECTIVE This narrative review will provide a description of scenarios in which TCD may be applicable. It will summarize the sonographic findings and associated underlying pathophysiology in such neurocritical care patients. An illustrated tutorial, along with pearls and pitfalls, is provided. DISCUSSION Although there are numerous formalized TCD protocols utilizing four views (transtemporal, submandibular, suboccipital, and transorbital), point-of-care TCD is best accomplished through the transtemporal window. The core applications include the evaluation of midline shift, vasospasm after subarachnoid hemorrhage, acute ischemic stroke, and elevated intracranial pressure. An illustrative tutorial is provided. CONCLUSIONS With the wide dissemination of bedside ultrasound within the emergency department, there is a unique opportunity for the emergency physician to utilize TCD for a variety of conditions. While barriers to training exist, emergency physician performance of limited point-of-care TCD is feasible and may provide rapid and reliable clinical information with high temporal resolution.
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Affiliation(s)
- Tim Montrief
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL 33136, USA.
| | - Stephen Alerhand
- Department of Emergency Medicine, Rutgers New Jersey Medical School, Newark, NJ 07103, USA
| | - Corlin Jewell
- Berbee Walsh Department of Emergency Medicine, University of Wisconsin School of Medicine and Public Health, Madison, WI 53705, USA
| | - Jeffery Scott
- Department of Emergency Medicine, Jackson Memorial Health System, Miami, FL 33136, USA
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11
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Transcranial Doppler Versus CT-Angiography for Detection of Cerebral Vasospasm in Relation to Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage: A Prospective Single-Center Cohort Study: The Transcranial doppler and CT-angiography for Investigating Cerebral vasospasm in Subarachnoid hemorrhage (TACTICS) study. Crit Care Explor 2019; 1:e0001. [PMID: 32166226 DOI: 10.1097/cce.0000000000000001] [Citation(s) in RCA: 16] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
Abstract
Cerebral vasospasm in the first 2 weeks after aneurysmal subarachnoid hemorrhage is recognized as a major predictor of delayed cerebral ischemia. The routine screening for cerebral vasospasm with either transcranial Doppler or CT angiography has been advocated, although its diagnostic value has not yet been determined. Our study investigated the diagnostic accuracy of detecting vasospasm by transcranial Doppler and CT angiography for the prediction of delayed cerebral ischemia and functional outcome. Additionally, agreement between transcranial Doppler and CT angiography was determined. Design Prospective diagnostic accuracy study. Settings Neurocritical care unit and neurosurgical ward at a tertiary academic medical center. Patients Between 2013 and 2016, 59 consenting patients were included. Intervention Patients undergo both transcranial Doppler and CT angiography for detection of cerebral vasospasm on days 5 and 10 after aneurysmal subarachnoid hemorrhage. Delayed cerebral ischemia was defined as secondary neurologic deterioration, not explained otherwise. Unfavorable outcome was defined modified Rankin Scale > 2 at 6 months. Measurements and Main Results On transcranial Doppler, cerebral vasospasm was observed in 26 patients (45%). On CT angiography, vasospasm was observed in 54 patients (95%). The agreement between transcranial Doppler and CT angiography was 0.47. Delayed cerebral ischemia occurred in 16 patients (27%); unfavorable outcome in 12 patients (20%). Transcranial Doppler predicted delayed cerebral ischemia with a sensitivity of 0.44 (day 5) and 0.50 (day 10), with a specificity of 0.67 (day 5) and 0.57 (day 10). CT angiography predicted delayed cerebral ischemia with a sensitivity of 0.81 (day 5 and 10) and with a specificity of 0.070 (day 5) and 0.00 (day 10). The highest accuracy for predicting unfavorable outcome was on day 5 (0.61 for transcranial Doppler vs 0.27 for CT angiography). Conclusion The diagnostic accuracy of both CT angiography and transcranial Doppler for detection of cerebral vasospasm as well as prediction of delayed cerebral ischemia and functional outcome is limited. The agreement between CT angiography and transcranial Doppler is low.
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12
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Al-Mufti F, Sursal T, Kim M, Menjivar AM, Cole C, Chandy D, Schmidt M, Bowers C, Gandhi CD. Noninvasive Multimodality Cerebral Monitoring Modalities in Neurosurgical Critical Care. World Neurosurg 2018; 121:249-250. [PMID: 30347294 DOI: 10.1016/j.wneu.2018.10.076] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/28/2022]
Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Tolga Sursal
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Michael Kim
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Alvaro Martin Menjivar
- Department of Internal Medicine - Division of Critical Care, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Chad Cole
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Dipak Chandy
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA; Department of Internal Medicine - Division of Critical Care, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Meic Schmidt
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Christian Bowers
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
| | - Chirag D Gandhi
- Department of Neurology and Neurosurgery, Westchester Medical Center at New York Medical College, Valhalla, New York, USA
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13
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Al-Mufti F, Lander M, Smith B, Morris NA, Nuoman R, Gupta R, Lissauer ME, Gupta G, Lee K. Multimodality Monitoring in Neurocritical Care: Decision-Making Utilizing Direct And Indirect Surrogate Markers. J Intensive Care Med 2018; 34:449-463. [PMID: 30205730 DOI: 10.1177/0885066618788022] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023]
Abstract
Substantial progress has been made to create innovative technology that can monitor the different physiological characteristics that precede the onset of secondary brain injury, with the ultimate goal of intervening prior to the onset of irreversible neurological damage. One of the goals of neurocritical care is to recognize and preemptively manage secondary neurological injury by analyzing physiologic markers of ischemia and brain injury prior to the development of irreversible damage. This is helpful in a multitude of neurological conditions, whereby secondary neurological injury could present including but not limited to traumatic intracranial hemorrhage and, specifically, subarachnoid hemorrhage, which has the potential of progressing to delayed cerebral ischemia and monitoring postneurosurgical interventions. In this study, we examine the utilization of direct and indirect surrogate physiologic markers of ongoing neurologic injury, including intracranial pressure, cerebral blood flow, and brain metabolism.
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Affiliation(s)
- Fawaz Al-Mufti
- 1 Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA.,2 Department of Neurosurgery, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Megan Lander
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Brendan Smith
- 4 Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Nicholas A Morris
- 5 Department of Neurology, University of Maryland Medical Center, Baltimore, MD, USA
| | - Rolla Nuoman
- 6 Department of Neurology, Rutgers University, New Jersey Medical School, Newark, NJ, USA
| | - Rajan Gupta
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Matthew E Lissauer
- 3 Division of Surgical Critical Care, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Gaurav Gupta
- 7 Division of Neurosurgery, Department of Surgery, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
| | - Kiwon Lee
- 1 Division of Neuroendovascular Surgery and Neurocritical Care, Department of Neurology, Rutgers University, Robert Wood Johnson Medical School, New Brunswick, NJ, USA
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14
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Al-Mufti F, Smith B, Lander M, Damodara N, Nuoman R, El-Ghanem M, Kamal N, Al-Marsoummi S, Alzubaidi B, Nuoaman H, Foreman B, Amuluru K, Gandhi CD. Novel minimally invasive multi-modality monitoring modalities in neurocritical care. J Neurol Sci 2018; 390:184-192. [PMID: 29801883 DOI: 10.1016/j.jns.2018.03.032] [Citation(s) in RCA: 10] [Impact Index Per Article: 1.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/26/2017] [Revised: 03/14/2018] [Accepted: 03/25/2018] [Indexed: 11/19/2022]
Abstract
Elevated intracranial pressure (ICP) following brain injury contributes to poor outcomes for patients, primarily by reducing the caliber of cerebral vasculature, and thereby reducing cerebral blood flow. Careful monitoring of ICP is critical in these patients in order to determine prognosis, implement treatment when ICP becomes elevated, and to judge responsiveness to treatment. Currently, the gold standard for monitoring is invasive pressure transducers, usually an intraventricular monitor, which presents significant risk of infection and hemorrhage. These risks made discovering non-invasive methods for monitoring ICP and cerebral perfusion a priority for researchers. Herein we sought to review recent publications on novel minimally invasive multi-modality monitoring techniques that provide surrogate data on ICP, cerebral oxygenation, metabolism and blood flow. While limitations in various forms preclude them from supplanting the use of invasive monitors, these modalities represent useful screening tools within our armamentarium that may be invaluable when the risks of invasive monitoring outweigh the associated benefits.
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Affiliation(s)
- Fawaz Al-Mufti
- Department of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States; Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States.
| | - Brendan Smith
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Megan Lander
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Nitesh Damodara
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Rolla Nuoman
- Department of Neurology, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Mohammad El-Ghanem
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Naveed Kamal
- Department of Neurosurgery, Rutgers University - New Jersey Medical School, Newark, NJ, United States
| | - Sarmad Al-Marsoummi
- Department of Biomedical Sciences, University of North Dakota, Grand Forks, ND, United States
| | - Basim Alzubaidi
- Department of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Halla Nuoaman
- Department of Neurology, Neurosurgery and Radiology, Westchester Medical Center at New York Medical College, Valhalla, NY, United States
| | - Brandon Foreman
- Department of Neurology and Rehabilitation Medicine, Division of Neurocritical Care, University of Cincinnati, Cincinnati, OH, United States
| | - Krishna Amuluru
- Department of Neurointerventional Radiology, University of Pittsburgh, Hamot, Erie, PA, United States
| | - Chirag D Gandhi
- Department of Neurosurgery, Westchester Medical Center - New York Medical College, Valhalla, NY, United States
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15
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Al-Mufti F, Amuluru K, Changa A, Lander M, Patel N, Wajswol E, Al-Marsoummi S, Alzubaidi B, Singh IP, Nuoman R, Gandhi C. Traumatic brain injury and intracranial hemorrhage–induced cerebral vasospasm: a systematic review. Neurosurg Focus 2017; 43:E14. [DOI: 10.3171/2017.8.focus17431] [Citation(s) in RCA: 33] [Impact Index Per Article: 4.7] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/04/2023]
Abstract
OBJECTIVELittle is known regarding the natural history of posttraumatic vasospasm. The authors review the pathophysiology of posttraumatic vasospasm (PTV), its associated risk factors, the efficacy of the technologies used to detect PTV, and the management/treatment options available today.METHODSThe authors performed a systematic review in accordance with the PRISMA (Preferred Reporting Items for Systematic Reviews and Meta-Analyses) guidelines using the following databases: PubMed, Google Scholar, and CENTRAL (the Cochrane Central Register of Controlled Trials). Outcome variables extracted from each study included epidemiology, pathophysiology, time course, predictors of PTV and delayed cerebral ischemia (DCI), optimal means of surveillance and evaluation of PTV, application of multimodality monitoring, modern management and treatment options, and patient outcomes after PTV. Study types were limited to retrospective chart reviews, database reviews, and prospective studies.RESULTSA total of 40 articles were included in the systematic review. In many cases of mild or moderate traumatic brain injury (TBI), imaging or ultrasonographic studies are not performed. The lack of widespread assessment makes finding the true overall incidence of PTV a difficult endeavor. The clinical consequences of PTV are important, given the morbidity that can result from it. DCI manifests as new-onset neurological deterioration that occurs beyond the timeframe of initial brain injury. While there are many techniques that attempt to diagnose cerebral vasospasm, digital subtraction angiography is the gold standard. Some predictors of PTV include SAH, intraventricular hemorrhage, low admission Glasgow Coma Scale (GCS) score (< 9), and young age (< 30 years).CONCLUSIONSGiven these results, clinicians should suspect PTV in young patients presenting with intracranial hemorrhage (ICH), especially SAH and/or intraventricular hemorrhage, who present with a GCS score less than 9. Monitoring and regulation of CNS metabolism following TBI/ICH-induced vasospasm may play an important adjunct role to the primary prevention of vasospasm.
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Affiliation(s)
- Fawaz Al-Mufti
- 1Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick
- Departments of 2Neurosurgery,
| | | | | | | | | | | | | | - Basim Alzubaidi
- 1Department of Neurology, Rutgers Robert Wood Johnson Medical School, New Brunswick
| | - I. Paul Singh
- Departments of 2Neurosurgery,
- 4Radiology, Rutgers University, New Jersey Medical School, Newark, New Jersey; and
| | | | - Chirag Gandhi
- Departments of 2Neurosurgery,
- 4Radiology, Rutgers University, New Jersey Medical School, Newark, New Jersey; and
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Jones S, Schwartzbauer G, Jia X. Brain Monitoring in Critically Neurologically Impaired Patients. Int J Mol Sci 2016; 18:E43. [PMID: 28035993 PMCID: PMC5297678 DOI: 10.3390/ijms18010043] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/14/2016] [Revised: 12/10/2016] [Accepted: 12/21/2016] [Indexed: 02/07/2023] Open
Abstract
Assessment of neurologic injury and the evolution of severe neurologic injury is limited in comatose or critically ill patients that lack a reliable neurologic examination. For common yet severe pathologies such as the comatose state after cardiac arrest, aneurysmal subarachnoid hemorrhage (aSAH), and severe traumatic brain injury (TBI), critical medical decisions are made on the basis of the neurologic injury. Decisions regarding active intensive care management, need for neurosurgical intervention, and withdrawal of care, depend on a reliable, high-quality assessment of the true state of neurologic injury, and have traditionally relied on limited assessments such as intracranial pressure monitoring and electroencephalogram. However, even within TBI there exists a spectrum of disease that is likely not captured by such limited monitoring and thus a more directed effort towards obtaining a more robust biophysical signature of the individual patient must be undertaken. In this review, multimodal monitoring including the most promising serum markers of neuronal injury, cerebral microdialysis, brain tissue oxygenation, and pressure reactivity index to access brain microenvironment will be discussed with their utility among specific pathologies that may help determine a more complete picture of the neurologic injury state for active intensive care management and long-term outcomes. Goal-directed therapy guided by a multi-modality approach appears to be superior to standard intracranial pressure (ICP) guided therapy and should be explored further across multiple pathologies. Future directions including the application of optogenetics to evaluate brain injury and recovery and even as an adjunct monitoring modality will also be discussed.
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Affiliation(s)
- Salazar Jones
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Gary Schwartzbauer
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Institute for Global Health, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
| | - Xiaofeng Jia
- Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Orthopaedics, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Anatomy and Neurobiology, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
- Department of Biomedical Engineering, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
- Department of Anesthesiology and Critical Care Medicine, The Johns Hopkins University School of Medicine, Baltimore, MD 21205, USA.
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Ding D. Contribution of cerebral vasospasm to delayed cerebral ischemia following aneurysmal subarachnoid hemorrhage. J Neurol Sci 2014; 336:293-4. [PMID: 24238998 DOI: 10.1016/j.jns.2013.10.044] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/26/2013] [Revised: 10/25/2013] [Accepted: 10/29/2013] [Indexed: 11/19/2022]
Affiliation(s)
- Dale Ding
- University of Virginia, Department of Neurological Surgery, P.O. Box 800212, Charlottesville, VA 22908, United States.
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Izzy S, Muehlschlegel S. Cerebral vasospasm after aneurysmal subarachnoid hemorrhage and traumatic brain injury. Curr Treat Options Neurol 2013; 16:278. [PMID: 24347030 DOI: 10.1007/s11940-013-0278-x] [Citation(s) in RCA: 20] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/25/2022]
Abstract
OPINION STATEMENT Cerebral vasospasm (cVSP) consists of the vasoconstriction of large and small intracranial vessels which can lead to cerebral hypoperfusion, and in extreme cases, delayed ischemic deficits with stroke. While most commonly observed after aneurysmal subarachnoid hemorrhage (aSAH), cVSP can also occur after traumatic brain injury (TBI) as we have described in detail in this review. For the past decades, the research attention has focused on cVSP because of its association with delayed cerebral ischemia, which is the largest contributor of morbidity and mortality after aSAH. New discoveries in the cVSP pathophysiology involving multifactorial complex cascades and pathways pose new targets for therapeutic interventions in the prevention and treatment of cVSP. The goal of this review is to demonstrate the commonalities and differences in epidemiology and pathophysiology of both aSAH and TBI-associated cVSP, and highlight the more recently discovered pathways of cVSP. Finally, the latest cVSP surveillance methods and treatment options are illustrated.
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Affiliation(s)
- Saef Izzy
- Department of Neurology (Neurocritical Care), University of Massachusetts Medical School, 55 Lake Ave North, S-5, Worcester, MA, 01655, USA
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Abstract
Subarachnoid haemorrhage (SAH) causes early brain injury (EBI) that is mediated by effects of transient cerebral ischaemia during bleeding plus effects of the subarachnoid blood. Secondary effects of SAH include increased intracranial pressure, destruction of brain tissue by intracerebral haemorrhage, brain shift, and herniation, all of which contribute to pathology. Many patients survive these phenomena, but deteriorate days later from delayed cerebral ischaemia (DCI), which causes poor outcome or death in up to 30% of patients with SAH. DCI is thought to be caused by the combined effects of angiographic vasospasm, arteriolar constriction and thrombosis, cortical spreading ischaemia, and processes triggered by EBI. Treatment for DCI includes prophylactic administration of nimodipine, and current neurointensive care. Prompt recognition of DCI and immediate treatment by means of induced hypertension and balloon or pharmacological angioplasty are considered important by many physicians, although the evidence to support such approaches is limited. This Review summarizes the pathophysiology of DCI after SAH and discusses established treatments for this condition. Novel strategies--including drugs such as statins, sodium nitrite, albumin, dantrolene, cilostazol, and intracranial delivery of nimodipine or magnesium--are also discussed.
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