A new method for the measurement of cerebral blood volume and total circulating blood volume using near infrared spatially resolved spectroscopy and indocyanine green: application and validation in neonates

Relationship of cerebral blood volume with arterial and venous flow velocities in extremely low-birth-weight infants

Unstable cerebral blood flow is theorised to contribute to the occurrence of intraventricular haemorrhage (IVH) in extremely low-birth-weight infants (ELBWIs), which can be caused by increased arterial flow, increased venous pressure, and impaired autoregulation of brain vasculature. As a preliminary step to investigate such instability, we aimed to check for correlations of cerebral blood volume (CBV), as measured using near-infrared spectroscopy, with the flow velocities of the anterior cerebral artery (ACA) and internal cerebral vein (ICV), as measured using Doppler ultrasonography. Data were retrospectively analysed from 30 ELBWIs uncomplicated by symptomatic patent ductus arteriosus, which can influence ACA velocity, and severe IVH (grade ≥ 3), which can influence ICV velocity and CBV. The correlation between tissue oxygen saturation (StO₂₎ and mean blood pressure was also analysed as an index of autoregulation. CBV was not associated with ACA velocity; however, it was significantly correlated with ICV velocity (Pearson R = 0.59 [95% confidence interval: 0.29-0.78], P = 0.00061). No correlation between StO₂ and mean blood pressure was observed, implying that autoregulation was not impaired.    Conclusion: Although our findings are based on the premise that cerebral autoregulation was unimpaired in the ELBWIs without complications, the same result cannot be directly applied to severe IVH cases. However, our results may aid future research on IVH prediction by investigating the changes in CBV when severe IVH occurs during ICV velocity fluctuation. What is Known: • The pathogenesis of IVH includes unstable cerebral blood flow affected by increased arterial flow, increased venous pressure, and impaired cerebral autoregulation. • The approaches that can predict IVH are under discussion. What is New: • ACA velocity is not associated with CBV, but ICV velocity is significantly correlated with CBV. • CBV measured using NIRS may be useful in future research on IVH prediction.

Red Blood Cell Transfusion in Preterm Infants: Current Evidence and Controversies

The current evidence regarding the indication, advantages and risks of red blood cell transfusion (RBCT) for preterm infants is discussed. This is an important area in Neonatology to be examined given that 90% of extremely low birth weight infants receive RBCT and many controversies remain regarding when to transfuse and the risks of RBCT. The various treatment thresholds and guidelines used are presented and we compare the short-term clinical benefits of liberal and restrictive RBCT in preterm infants; the majority of these are equivocal and sadly long-term outcome data is limited. The latest evidence on how anaemia and blood transfusion affect organ perfusion in preterm infants is presented. This is important when trying to establish the optimal trigger threshold for RBCT in preterm infants, especially because the knowledge about the adaptive physiological responses to anaemia in very low birth weight infants and the effects of RBCT at various levels of anaemia is also inadequate. Further research into the physiological adaptive response to anaemia of varying degrees and to RBCT at different levels of anaemia in preterm infants of different gestational and post-natal ages is needed before we can conclusively guide the optimal timing and trigger thresholds for RBCT in preterm infants.

Application of optical methods in the monitoring of traumatic brain injury: A review

We present an overview of the wide range of potential applications of optical methods for monitoring traumatic brain injury. The MEDLINE database was electronically searched with the following search terms: "traumatic brain injury," "head injury," or "head trauma," and "optical methods," "NIRS," "near-infrared spectroscopy," "cerebral oxygenation," or "cerebral oximetry." Original reports concerning human subjects published from January 1980 to June 2015 in English were analyzed. Fifty-four studies met our inclusion criteria. Optical methods have been tested for detection of intracranial lesions, monitoring brain oxygenation, assessment of brain perfusion, and evaluation of cerebral autoregulation or intracellular metabolic processes in the brain. Some studies have also examined the applicability of optical methods during the recovery phase of traumatic brain injury . The limitations of currently available optical methods and promising directions of future development are described in this review. Considering the outstanding technical challenges, the limited number of patients studied, and the mixed results and opinions gathered from other reviews on this subject, we believe that optical methods must remain primarily research tools for the present. More studies are needed to gain confidence in the use of these techniques for neuromonitoring of traumatic brain injury patients.

Blood transfusion in preterm infants improves intestinal tissue oxygenation without alteration in blood flow

BACKGROUND AND OBJECTIVE

The objective of the study was to investigate the splanchnic blood flow velocity and oximetry response to blood transfusion in preterm infants according to postnatal age.

MATERIALS AND METHODS

Preterm infants receiving blood transfusion were recruited to three groups: 1-7 (group 1; n = 20), 8-28 (group 2; n = 21) and ≥29 days of life (group 3; n = 18). Superior mesenteric artery (SMA) peak systolic (PSV) and diastolic velocities were measured 30-60 min pre- and post-transfusion using Doppler ultrasound scan. Splanchnic tissue haemoglobin index (sTHI), tissue oxygenation index (sTOI) and fractional tissue oxygen extraction (sFTOE) were measured from 15-20 min before to post-transfusion using near-infrared spectroscopy.

RESULTS

The mean pretransfusion Hb in group 1, 2 and 3 was 11, 10 and 9 g/dl, respectively. The mean (SD) pretransfusion SMA PSV in group 1, 2 and 3 was 0·63 (0·32), 0·81 (0·33) and 0·97 (0·40) m/s, respectively, and this did not change significantly following transfusion. The mean (SD) pretransfusion sTOI in group 1, 2 and 3 was 36·7 (19·3), 44·6 (10·4) and 41·3 (10·4)%, respectively. The sTHI and sTOI increased (P < 0·01), and sFTOE decreased (P < 0·01) following transfusion in all groups. On multivariate analysis, changes in SMA PSV and sTOI following blood transfusion were not associated with PDA, feeding, pretransfusion Hb and mean blood pressure.

CONCLUSION

Pretransfusion baseline splanchnic tissue oximetry and blood flow velocity varied with postnatal age. Blood transfusion improved intestinal tissue oxygenation without altering mesenteric blood flow velocity irrespective of postnatal ages.

Cerebral blood flow and oximetry response to blood transfusion in relation to chronological age in preterm infants

OBJECTIVE

Preterm infants frequently receive blood transfusion (BT) and the aim of this study was to measure the effect of BT on cerebral blood flow and oxygenation in preterm infants in relation to chronological age.

PATIENTS

Preterm infants undergoing intensive care recruited to three chronological age groups: 1 to 7 (Group 1; n=20), 8 to 28 (Group 2; n=21) & ≥29days of life (Group 3; n=18).

METHODS

Pre and post-BT anterior cerebral artery (ACA) time averaged mean velocity (TAMV) and superior vena cava (SVC) flow were measured. Cerebral Tissue Haemoglobin Index (cTHI) and Oxygenation Index (cTOI) were measured from 15-20min before to 15-20min post-BT using NIRS. Vital parameters and blood pressure were measured continuously.

RESULTS

Mean BP increased significantly, and there was no significant change in vital parameters following BT. Pre-BT ACA TAMV was higher in Group 2 and 3 compared to Group 1 (p<0.001). Pre-BT ACA TAMV decreased significantly (p≤0.04) in all 3 groups; pre-BT SVC flow decreased significantly in Group 1 (p=0.03) and Group 3 (p<0.001) following BT. Pre-BT cTOI was significantly lower in Group 3 compared to Group 1 (p=0.02). cTHI (p<0.001) and cTOI (p<0.05) increased significantly post-BT in all three groups. PDA had no effect on these measurements.

CONCLUSION

Baseline cTOI decreases and ACA TAMV increases with increasing chronological age. Blood transfusion increased cTOI and cTHI and decreased ACA TAMV in all groups. PDA had no impact on the baseline cerebral oximetry and blood flow as well as changes following blood transfusion.

Computational optimization of the configuration of a spatially resolved spectroscopy sensor for milk analysis

A global optimizer has been developed, capable of computing the optimal configuration in a probe for spatially resolved reflectance spectroscopy (SRS). The main objective is to minimize the number of detection fibers, while maintaining an accurate estimation of both absorption and scattering profiles. Multiple fibers are necessary to robustify the estimation of optical properties against noise, which is typically present in the measured signals and influences the accuracy of the inverse estimation. The optimizer is based on a robust metamodel-based inverse estimation of the absorption coefficient and a reduced scattering coefficient from the acquired SRS signals. A genetic algorithm is used to evaluate the effect of the fiber placement on the performance of the inverse estimator to find the bulk optical properties of raw milk. The algorithm to find the optimal fiber placement was repeatedly executed for cases with a different number of detection fibers, ranging from 3 to 30. Afterwards, the optimal designs for each considered number of fibers were compared based on their performance in separating the absorption and scattering properties, and the significance of the differences was tested. A sensor configuration with 13 detection fibers was found to be the combination with the lowest number of fibers which provided an estimation performance which was not significantly worse than the one obtained with the best design (30 detection fibers). This design resulted in the root mean squared error of prediction (RMSEP) of 1.411 cm(-1) (R(2) = 0.965) for the estimation of the bulk absorption coefficient values, and 0.382 cm(-1) (R(2) = 0.996) for the reduced scattering coefficient values.

Effect of blood transfusion on intestinal blood flow and oxygenation in extremely preterm infants during first week of life

BACKGROUND

Extremely preterm infants receive frequent blood transfusions in the first week of life. The aim of this study was to measure the effect of blood transfusion on intestinal blood flow and oxygenation during the first week of life in extremely preterm infants.

STUDY DESIGN AND METHODS

Superior mesenteric artery (SMA) peak systolic velocity (PSV) and diastolic velocities were measured 30 to 60 minutes before and after transfusion. Splanchnic tissue hemoglobin index (sTHI), splanchnic tissue oxygenation index (sTOI), and splanchnic fractional tissue oxygen extraction (sFTOE) were measured continuously from 15 to 20 minutes before to after transfusion along with vital variables.

RESULTS

Twenty infants were studied (median gestational age, 26 weeks). Ten infants were partially fed (15-68 mL/kg/day). Heart rate and SaO2 remained unaltered; blood pressure increased significantly (p < 0.01) after transfusion. Mean SMA PSV (p = 0.63) and diastolic velocity (p = 0.65) remained unaltered. Mean pretransfusion SMA PSV was similar in partially fed (0.78 m/sec) compared to unfed infants (0.52 m/sec; p = 0.06) and the response to transfusion was not dissimilar. There was a significant increase in sTHI (mean difference, 32.3%; p < 0.01) and sTOI (14.6%; p = 0.03) and decrease in sFTOE (22.1%; p < 0.01) after transfusion. There was no significant difference in sTHI or sTOI between fed and unfed infants and their response to transfusion.

CONCLUSIONS

Blood transfusion increased blood pressure and intestinal tissue oxygenation but did not alter blood flow velocities. Partial feeding had no impact on intestinal blood flow and tissue oxygenation changes.

Robust metamodel-based inverse estimation of bulk optical properties of turbid media from spatially resolved diffuse reflectance measurements

Estimation of the bulk optical properties of turbid samples from spatially resolved reflectance measurements remains challenging, as the relation between the bulk optical properties and the acquired spatially resolved reflectance profiles is influenced by wavelength-dependent properties of the measurement system. The resulting measurement noise is apparent in the estimation of the bulk optical properties. In this study, a constrained inverse metamodeling approach is proposed to overcome these problems. First, a metamodel has been trained on a set of intralipid phantoms covering a wide range of optical properties to link the acquired spatially resolved reflectance profiles to the respective combinations of bulk optical properties (absorption coefficient and reduced scattering coefficient). In this metamodel, the wavelength (500 - 1700 nm) is considered as a third input parameter for the model to account for the wavelength dependent effects introduced by the measurement system. Secondly, a smoothness constraint on the reduced scattering coefficient spectra was implemented in the iterative inverse estimation procedure to robustify it against measurement noise and increase the reliability of the obtained bulk absorption and reduced scattering coefficient spectra. As the estimated values in some regions may be more reliable than others, the difference between simulated and measured values as a function of the evaluated absorption and scattering coefficients was combined in a 2D cost function. This cost function was used as a weight in the fitting procedure to find the parameters of the µ(s)' function giving the lowest cost over all the wavelengths together. In accordance with previous research, an exponential function was considered to represent the µ(s)' spectra of intralipid phantoms. The fitting procedure also provides an absorption coefficient spectrum which is in accordance with the measurements and the estimated parameters of the exponential function. This robust inverse estimation algorithm was validated on an independent set of intralipid® phantoms and its performance was also compared to that of a classical single-wavelength inverse estimation algorithm. While its performance in estimating µ(a) was comparable (R2 of 0.844 vs. 0.862), it resulted in a large improvement in the estimation of µ(s)' (R2 of 0.987 vs. 0.681). The change in performance is more apparent in the improvement of RMSE of µ(s)', which decreases from 10.36 cm(-1) to 2.10 cm(-1). The SRS profiles change more sensitively as a function of µ(a). As a result, there is a large range of µ(s)' and a small range of µa resulting in a good fit between measurement and simulation. The robust inverse estimator incorporates information over the different wavelengths, to increase the accuracy of µ(s)'estimations and robustify the estimation process.

Evaluation of cerebral circulation and oxygen metabolism in infants using near-infrared light

Bedside monitoring of cerebral circulation or oxygen metabolism in infants to appropriately manage circulation and establish the oxygen dose, aiming at improving the neurological prognosis, is needed in general clinical practice. Near-infrared spectroscopy is used for measurements of neonatal cerebral Hb oxygen saturation, cerebral blood volume, cerebral blood flow and cerebral metabolic rate of oxygen. Near-infrared time-resolved spectroscopy is particularly useful for bedside evaluation of cerebral circulation and oxygen metabolism because of its simple measurement procedure. Combined evaluation of cerebral blood volume and cerebral Hb oxygen saturation is expected to contribute to treatment centering on the brain in neonatal medical care.

Neurotoxic effects of indocyanine green -cerebellar granule cell culture viability study

The aim of this study was to examine neurotoxicity indocyanine green (ICG). We assessed viability of primary cerebellar granule cell culture (CGC) exposed to ICG to test two mechanisms that could be the first triggers causing neuronal toxicity: imbalance in calcium homeostasis and the degree of oligomerization of ICG molecules. We have observed this imbalance in CGC after exposure to 75-125μΜ ICG and dose and application sequence dependent protective effect of Gadovist on surviving neurons in vitro when used with ICG. Spectroscopic studies suggest the major cause of toxicity of the ICG is connected with oligomers formation. ICG at concentration of 25 μM (which is about 4 times higher than the highest concentration of ICG in the brain applied in in-vivo human studies) is not neurotoxic in the cell culture.

Difference in cerebral and peripheral hemodynamics among term and preterm infants during the first three days of life

BACKGROUND

The relationship between cerebral and peripheral hemodynamics during the early postnatal period has not been clarified.

OBJECTIVES

To evaluate cerebral and peripheral oxygenation and blood volumes between term and preterm infants during the first 3 days of life.

MATERIALS AND METHODS

We performed near-infrared time-resolved spectroscopy on 32 term infants (term group) and 40 preterm infants (preterm group), with an optode placed on their forehead and upper arm. The cerebral blood volume (CBV), peripheral blood volume (PBV), cerebral Hb oxygen saturation (cSO2) and peripheral Hb oxygen saturation (pSO2) were measured at 3-6, 12, 24, 48 and 72 h after birth.

RESULTS

The CBV in the term group (2.45 ± 0.47 ml/100 g) was significantly higher than that in the preterm group (1.97 ± 0.33 ml/100 g). In contrast to the CBV, the PBV in the preterm group (3.63 ± 0.76 ml/100 g) was significantly higher than that in the term group (3.26 ± 0.56 ml/100 g). In the preterm group, there was a significant positive relationship between the CBVs and PBVs at each time point except at 72 h after birth. Despite the differences in blood volumes, there were no differences in the cSO2 and pSO2 between the two groups.

CONCLUSIONS

The contrasting results in the CBV and PBV between the term and preterm infants might be explained by differences in the maturation of the physiological mechanism to control CBV and PBV.

Metamodeling approach for efficient estimation of optical properties of turbid media from spatially resolved diffuse reflectance measurements

A metamodeling approach is introduced and applied to efficiently estimate the bulk optical properties of turbid media from spatially resolved spectroscopy (SRS) measurements. The model has been trained on a set of liquid phantoms covering a wide range of optical properties representative for food and agricultural products and was successfully validated in forward and inverse mode on phantoms not used for training the model. With relative prediction errors of 10% for the estimated bulk optical properties the potential of this metamodeling approach for the estimation of the optical properties of turbid media from spatially resolved spectroscopy measurements has been demonstrated.

Assessment of cerebral perfusion in post-traumatic brain injury patients with the use of ICG-bolus tracking method

The aim of this study was to verify the usefulness of the time-resolved optical method utilizing diffusely reflected photons and fluorescence signals combined with intravenous injection of indocyanine green (ICG) in the assessment of brain perfusion in post-traumatic brain injury patients. The distributions of times of flight (DTOFs) of diffusely reflected photons were acquired together with the distributions of times of arrival (DTAs) of fluorescence photons. The data analysis methodology was based on the observation of delays between the signals of statistical moments (number of photons, mean time of flight and variance) of DTOFs and DTAs related to the inflow of ICG to the extra- and intracerebral tissue compartments. Eleven patients with brain hematoma, 15 patients with brain edema and a group of 9 healthy subjects were included in this study. Statistically significant differences between parameters obtained in healthy subjects and patients with brain hematoma and brain edema were observed. The best optical parameter to differentiate patients and control group was variance of the DTOFs or DTAs. Results of the study suggest that time-resolved optical monitoring of inflow of the ICG seems to be a promising tool for detecting cerebral perfusion insufficiencies in critically ill patients.

Preservation of the metabolic rate of oxygen in preterm infants during indomethacin therapy for closure of the ductus arteriosus

BACKGROUND

The aim of this study was to assess and quantify the effects of indomethacin on cerebral blood flow (CBF), oxygen extraction fraction (OEF), and cerebral metabolic rate of oxygen (CMRO2) in preterm infants undergoing treatment for a patent ductus arteriosus (PDA).

METHODS

CBF and CMRO2 were measured before and after the first dose of a 3-d course of indomethacin to close hemodynamically significant PDA in preterm neonates. Indocyanine-green (ICG) concentration curves were acquired before and after indomethacin injection to quantify CBF and CMRO2.

RESULTS

Eight preterm neonates (gestational age, 27.6 ± 0.5 wk; birth weight, 992 ± 109 g; 6 males:2 females) were treated at a median age of 4.5 d (range, 4-21 d). Indomethacin resulted in an average CBF decrease of 18% (pre- and post-CBF = 12.9 ± 1.3 and 10.6 ± 0.8 ml/100 g/min, respectively) and an OEF increase of 11% (pre- and post-OEF = 0.38 ± 0.02 and 0.42 ± 0.02, respectively) but no significant change in CMRO2 (pre- and post-CMRO2 = 0.83 ± 0.07 and 0.76 ± 0.07 ml O2/100 g/min, respectively). Corresponding mean blood pressure (BP), arterial oxygen saturation (SaO2), heart rate, and end-tidal carbon dioxide tension levels remained unchanged.

CONCLUSION

Indomethacin resulted in significant reduction in CBF but did not alter CMRO2 because of a compensatory increase in OEF.

Monitoring angiogenesis using a human compatible calibration for broadband near-infrared spectroscopy

Angiogenesis is a hallmark of many conditions, including cancer, stroke, vascular disease, diabetes, and high-altitude exposure. We have previously shown that one can study angiogenesis in animal models by using total hemoglobin (tHb) as a marker of cerebral blood volume (CBV), measured using broadband near-infrared spectroscopy (bNIRS). However, the method was not suitable for patients as global anoxia was used for the calibration. Here we determine if angiogenesis could be detected using a calibration method that could be applied to patients. CBV, as a marker of angiogenesis, is quantified in a rat cortex before and after hypoxia acclimation. Rats are acclimated at 370-mmHg pressure for three weeks, while rats in the control group are housed under the same conditions, but under normal pressure. CBV increased in each animal in the acclimation group. The mean CBV (%volume/volume) is 3.49%± 0.43% (mean ± SD) before acclimation for the experimental group, and 4.76%± 0.29% after acclimation. The CBV for the control group is 3.28%± 0.75%, and 3.09%± 0.48% for the two measurements. This demonstrates that angiogenesis can be monitored noninvasively over time using a bNIRS system with a calibration method that is compatible with human use and less stressful for studies using animals.

Calibration of a prototype NIRS oximeter against two commercial devices on a blood-lipid phantom

In a blood-lipid liquid phantom the prototype near-infrared spectroscopy oximeter OxyPrem was calibrated against the INVOS® 5100c adult sensor in respect to values of regional tissue oxygen haemoglobin saturation (rStO2) for possible inclusion in the randomised clinical trial - SafeBoosC. In addition different commercial NIRS oximeters were compared on changing haemoglobin oxygen saturation and compared against co-oximetry. The best calibration was achieved with a simple offset and a linear scaling of the OxyPrem rStO2 values. The INVOS adult and pediatric sensor gave systematically different values, while the difference between the NIRO® 300 and the two INVOS sensors were magnitude dependent. The co-oximetry proved unreliable on such low haemoglobin and high Intralipid levels.

Nonpharmacological, blood conservation techniques for preventing neonatal anemia--effective and promising strategies for reducing transfusion

The development of anemia after birth in very premature, critically ill newborn infants is a universal well-described phenomenon. Although preventing anemia in this population, along with efforts to establish optimal red blood cell (RBC) transfusion and pharmacologic therapy continue to be actively investigated, the present review focuses exclusively on nonpharmacological approaches to the prevention and treatment of neonatal anemia. We begin with an overview of topics relevant to nonpharmacological techniques. These topics include neonatal and fetoplacental hemoglobin levels and blood volumes, clinical and laboratory practices applied in critically ill neonates, and current RBC transfusion practice guidelines. This is followed by a discussion of the most effective and promising nonpharmacological blood conservation strategies and techniques. Fortunately, many of these techniques are feasible in most neonatal intensive care units. When applied together, these techniques are more effective than existing pharmacotherapies in significantly decreasing neonatal RBC transfusions. They include increasing hemoglobin endowment and circulating blood volume at birth; removing less blood for laboratory testing; and optimizing nutrition.

Wavelength-resolved measurements of fluorescence lifetime of indocyanine green

We study fluorescence lifetime of indocyanine green (ICG) using femtosecond laser and sensitive detection based on time-correlated single-photon counting. A time-resolved multichannel spectral system is constructed and applied for determination of the fluorescence lifetime of the ICG in different solvents. Emission properties of ICG in water, milk, and 1% intralipid solution are investigated. Fluorescence of the fluorophore of different concentrations (in a range of 1.7-160 μM) dissolved in different solutions is excited by femtosecond pulses generated with the use of Ti:Sa laser tuned within the range of 740-790 nm. It is observed that fluorescence lifetime of ICG in water is 0.166 ± 0.02 ns and does not depend on excitation and emission wavelengths. We also show that for the diffusely scattering solvents (milk and intralipid), the lifetime may depend on the dye concentration (especially for large concentrations of ICG). This effect should be taken into account when analyzing changes in the mean time of arrival of fluorescence photons excited in ICG dissolved in such optically turbid media.

Assessment of inflow and washout of indocyanine green in the adult human brain by monitoring of diffuse reflectance at large source-detector separation

Recently, it was shown in measurements carried out on humans that time-resolved near-infrared reflectometry and fluorescence spectroscopy may allow for discrimination of information originating directly from the brain avoiding influence of contaminating signals related to the perfusion of extracerebral tissues. We report on continuation of these studies, showing that the near-infrared light can be detected noninvasively on the surface of the tissue at large interoptode distance. A multichannel time-resolved optical monitoring system was constructed for measurements of diffuse reflectance in optically turbid medium at very large source-detector separation up to 9 cm. The instrument was applied during intravenous injection of indocyanine green and the distributions of times of flight of photons were successfully acquired showing inflow and washout of the dye in the tissue. Time courses of the statistical moments of distributions of times of flight of photons are presented and compared to the results obtained simultaneously at shorter source-detector separations (3, 4, and 5 cm). We show in a series of experiments carried out on physical phantom and healthy volunteers that the time-resolved data acquisition in combination with very large source-detector separation may allow one to improve depth selectivity of perfusion assessment in the brain.

Near-infrared spectroscopy: a methodology-focused review

Near infrared spectroscopy (NIRS) is a light-based technology used to monitor tissue oxygen status. Refinements to the method since it was first described have extended its applicability to different research and clinical settings due to its non-invasiveness, instrument portability and ease of use. Classic NIRS recordings, based in the Beer-Lambert law, can be used for the trend monitoring of changes in tissue perfusion-oxygenation parting from an arbitrary zero point. However, in order to derive intermittently quantitative values in absolute terms, certain manoeuvres must be performed. More recently, the evolution of the technique has led to the development of instruments that provide an absolute value of regional hemoglobin saturation in a continuous manner. This review will focus on the physical principles of tissue spectroscopy including a brief description of the different operating principles that are currently in use or under development. The theoretical details, experimental procedures and data analysis involved in the measurements of physiological variables using NIRS will be described. The future beyond the scope of NIRS and potential lines of research will also be discussed.

Noninvasive optical measures of CBV, StO(2), CBF index, and rCMRO(2) in human premature neonates' brains in the first six weeks of life

With the causes of perinatal brain injuries still unclear and the probable role of hemodynamic instability in their etiology, bedside monitoring of neonatal cerebral hemodynamics with standard values as a function of age are needed. In this study, we combined quantitative frequency domain near infrared spectroscopy (FD-NIRS) measures of cerebral tissue oxygenation (StO(2)) and cerebral blood volume (CBV) with diffusion correlation spectroscopy (DCS) measures of a cerebral blood flow index (CBF(ix)) to test the validity of the CBV-CBF relationship in premature neonates and to estimate cerebral metabolic rate of oxygen (rCMRO(2)) with or without the CBF(ix) measurement. We measured 11 premature neonates (28-34 weeks gestational age) without known neurological issues, once a week from one to six weeks of age. In nine patients, cerebral blood velocities from the middle cerebral artery were collected by transcranial Doppler (TCD) and compared with DCS values. Results show a steady decrease in StO(2) during the first six weeks of life while CBV remains stable, and a steady increase in CBF(ix). rCMRO(2) estimated from FD-NIRS remains constant but shows wide interindividual variability. rCMRO(2) calculated from FD-NIRS and DCS combined increased by 40% during the first six weeks of life with reduced interindividual variability. TCD and DCS values are positively correlated. In conclusion, FD-NIRS combined with DCS offers a safe and quantitative bedside method to assess CBV, StO(2), CBF, and rCMRO(2) in the premature brain, facilitating individual follow-up and comparison among patients. A stable CBV-CBF relationship may not be valid for premature neonates.

Is mean blood saturation a useful marker of tissue oxygenation?

Increasingly we are monitoring the distribution of oxygen through the microcirculation using optical techniques such as optical reflectance spectroscopy (ORS) and near-infrared spectroscopy. Mean blood oxygen saturation (SmbO2) and tissue oxygenation index measured by these two techniques, respectively, evoke a concept of the measurement of oxygen delivery to tissue. This study aims to establish whether SmbO2 is an appropriate indicator of tissue oxygenation. Spontaneous fluctuations in SmbO2 observed as changes in concentration of oxyhemoglobin ([HbO2]) and deoxyhemoglobin ([Hb]) were measured by ORS in the skin microcirculation of 30 healthy subjects (15 men, age 21–42 yr). Fourier analysis identified two distinctly different spontaneous falls in SmbO2. The first type of swing, thought to be induced by fluctuations in arterial blood volume, resulted from the effects of respiration, endothelial, sympathetic, and myogenic activity. There was no apparent change in [Hb]. In contrast, a second type of swing resulted from a fall in [HbO2] accompanied by a rise in [Hb] and was only induced by endothelial and sympathetic activity. Thus the same fall in SmbO2 can be induced by two distinct responses. A “type I” swing does not suggest an inadequacy in oxygen delivery whereas a “type II” swing may indicate a change in oxygen delivery from blood to tissue. SmbO2 alone cannot therefore be accepted as a definitive marker of tissue oxygenation.

Quantitative analysis of peripheral tissue perfusion using spatiotemporal molecular dynamics

Background

Accurate measurement of peripheral tissue perfusion is challenging but necessary to diagnose peripheral vascular insufficiency. Because near infrared (NIR) radiation can penetrate relatively deep into tissue, significant attention has been given to intravital NIR fluorescence imaging.

Methodology/Principal Findings

We developed a new optical imaging-based strategy for quantitative measurement of peripheral tissue perfusion by time-series analysis of local pharmacokinetics of the NIR fluorophore, indocyanine green (ICG). Time-series NIR fluorescence images were obtained after injecting ICG intravenously in a murine hindlimb ischemia model. Mathematical modeling and computational simulations were used for translating time-series ICG images into quantitative pixel perfusion rates and a perfusion map. We could successfully predict the prognosis of ischemic hindlimbs based on the perfusion profiles obtained immediately after surgery, which were dependent on the preexisting collaterals. This method also reflected increases in perfusion and improvements in prognosis of ischemic hindlimbs induced by treatment with vascular endothelial growth factor and COMP-angiopoietin-1.

Conclusions/Significance

We propose that this novel NIR-imaging-based strategy is a powerful tool for biomedical studies related to the evaluation of therapeutic interventions directed at stimulating angiogenesis.

Monitoring angiogenesis noninvasively with near-infrared spectroscopy

Near-infrared (NIR) spectroscopy is used to quantify cerebral blood volume (CBV) as a marker of angiogenesis (formation of new blood vessels). Rats are exposed to chronic hypoxia for 3 weeks at half atmospheric pressure to stimulate angiogenesis, and second-differential NIR spectroscopy is used to quantify total cerebral hemoglobin before and after angiogenesis. The cerebral hemoglobin (from broadband NIR spectroscopy), and the large vessel hemoglobin and hematocrit (from blood samples), are used to derive values for the calculation of CBV. The total hemoglobin in brain is 46.6+/-1.9 micromoll (mean+/-SD, n=5) preacclimation and increases by 72% postacclimation. CBV is initially 3.26+/-0.41% v/v and increases by 31% with acclimation. Each individual animal shows a measureable increase in CBV. This study indicates that NIR broadband spectroscopy can be used for repeated measurements of CBV and can be applied as a noninvasive method to study angiogenesis.

Measuring circulating blood volume in newborn infants using pulse dye densitometry and indocyanine green

BACKGROUND

Circulating blood volume (BV) is an important, but often unconsidered, variable in newborn infants undergoing intensive care. The data on validation and repeatability of BV measurement are limited.

AIM

To validate and test the repeatability of measuring BV in newborn infants using indocyanine green (ICG) and pulse dye densitometry (PDD).

METHODS

Validation--Paired measurements of BV were made using the fetal hemoglobin (HbF) dilution and the PDD method. Repeatability--The BV was measured twice at an interval of 30-40 min in a second group of infants.

RESULTS

Validation--Data from three of 13 infants studied were excluded because of probe dislodgement or ICG injection error. The median (range) birth weight of the 10 infants whose data were analyzed was 1032 g (740-2384 g) and seven (70%) were receiving either mechanical ventilation or nasal CPAP. The median BV measured by HbF dilution was 66.2 ml x kg(-1) (43.7-81.0 ml x kg(-1)) and by the PDD method was 68.9 ml x kg(-1) (49.3-101.0 ml x kg(-1)). The mean difference was 5.92 ml x kg(-1) (SD 17.33 ml x kg(-1)). Repeatability--Twelve infants were studied and three excluded because of probe dislodgement/motion artifact or ICG injection error. The median weight of the nine infants whose data were analyzed was 1208 g (795-2600 g). The median (range) BV1 and BV2 were 70.5 ml x kg(-1) (53.1-160 ml x kg(-1)) and 87.5 ml x kg(-1) (38.0-248.0 ml x kg(-1)), respectively. Mean difference of the two BV estimates (BV1-BV2) was -24.6 ml x kg(-1) (SD 33.3 ml x kg(-1)) and coefficient of repeatability was 66.5 ml x kg(-1).

CONCLUSION

Pulse dye densitometry can be used to measure BV in the newborn infant at the cotside but the repeatability measurements suggest that its use is limited.

Optical brain imaging in vivo: techniques and applications from animal to man

Optical brain imaging has seen 30 years of intense development, and has grown into a rich and diverse field. In-vivo imaging using light provides unprecedented sensitivity to functional changes through intrinsic contrast, and is rapidly exploiting the growing availability of exogenous optical contrast agents. Light can be used to image microscopic structure and function in vivo in exposed animal brain, while also allowing noninvasive imaging of hemodynamics and metabolism in a clinical setting. This work presents an overview of the wide range of approaches currently being applied to in-vivo optical brain imaging, from animal to man. Techniques include multispectral optical imaging, voltage sensitive dye imaging and speckle-flow imaging of exposed cortex, in-vivo two-photon microscopy of the living brain, and the broad range of noninvasive topography and tomography approaches to near-infrared imaging of the human brain. The basic principles of each technique are described, followed by examples of current applications to cutting-edge neuroscience research. In summary, it is shown that optical brain imaging continues to grow and evolve, embracing new technologies and advancing to address ever more complex and important neuroscience questions.

Near-infrared spectroscopy in the fetus and neonate

Near-infrared spectroscopy allows for real-time, noninvasive measurement of cerebral hemodynamics and oxygenation at the bed-side. This article describes animal and clinical research using near-infrared spectroscopy to study cerebral hemodynamic function in the fetus, neonate, and child.

Measurement of the absolute optical properties and cerebral blood volume of the adult human head with hybrid differential and spatially resolved spectroscopy

A hybrid differential and spatially resolved spectroscopy (SRS) technique has been developed to measure absolute absorption coefficient (mu(a)), reduced scattering coefficient (mu'(s)) and cerebral blood volume (CBV) in the adult human head. A spectrometer with both differential and SRS capabilities has been used to carry out measurements in 12 subjects. Two versions of the calculation have been considered using the hybrid technique, with one considering water as a chromophore as well as oxy- and deoxy-haemoglobin, and one ignoring water. The CBV has also been measured using a previously described technique based on changing the arterial saturation (SaO(2)) measured separately by a pulse oximeter, resulting in mean +/- SD CBV(a) (intra-individual coefficient of variation) = 2.22 +/- 1.06 ml/100 g (29.9%). (The superscript on CBV indicates the different calculation basis.) Using the hybrid technique with water ignored, CBV(0) = 3.18 +/- 0.73 ml/100 g (10.0%), mu(0)(a)(813 nm) = 0.010 +/- 0.003 mm(-1) and mu'(0)(s)(813 nm) = 1.19 +/- 0.55 mm(-1) (data quoted at 813 nm). With water considered, CBV(w) = 3.05 +/- 0.77 ml/100 g (10.5%), mu(w)(a)(813 nm) = 0.010 +/- 0.003 mm(-1) and mu'(w)(s)(813 nm) = 1.28 +/- 0.56 mm(-1). The mean biases between CBV(0)/CBV(w), CBV(0)/CBV(a) and CBV(w)/CBV(a) are 0.14 +/- 0.09, 0.79 +/- 1.22 and 0.65 +/- 1.24 ml/100 g. The mean biases between mu(0)(a)(813 nm)/mu(w)(a)(813 nm) and mu'(0)(s)(813 nm)/mu'(w)(s)(813 nm) are (5.9 +/- 10.0) x 10(-4) mm(-1) and -0.084 +/- 0.266 mm(-1), respectively. The method we describe extends the functionality of the current SRS instrumentation.

Estimation of cerebral oxy- and deoxy-haemoglobin concentration changes in a layered adult head model using near-infrared spectroscopy and multivariate statistical analysis

The non-invasive measurement of cerebral oxy- (DeltaHbO(br)2) and deoxy-haemoglobin (DeltaHHb(br)) changes using near-infrared spectroscopy instruments is often affected by the absorption in the extracerebral layer. We have exploited the multivariate calibration (partial least squares, PLS) method to minimize the errors for a range of blood volume, oxygen saturation and extracerebral layer thicknesses. The changes in the mean time of flight of photons (Delta tau) and attenuation (DeltaA) on the surface of a 3D adult head model were simulated using a finite-element method based on the diffusion equation. The PLS was then performed to identify the optimal number of detectors, their positions and weightings, to optimize the estimation of DeltaHbO(br)2 and DeltaHHb(br). We define the 'nominal accuracy' as the accuracy of estimating DeltaHbO(br)2 and DeltaHHb(br) over a nominal range of extracerebral layer thicknesses and 'robustness' as the accuracy beyond the nominal range. The results showed that for one or two detectors, Delta tau performed better than DeltaA while using them together gave the best performance. When more detectors were used, the performances of using Delta tau, DeltaA or both together became comparable, showing that a larger number of detectors can compensate for the performance of a simple DeltaA measurement despite this measurement having a relatively lower sensitivity to intracerebral absorption changes.

A comparison of two blood culture procedures for the isolation of staphylococci in a paediatric intensive care unit

Blood culture results obtained between January 2000 and July 2003 were reviewed for 1360 patients in a paediatric intensive care unit (PICU). The BacT/Alert FA aerobic medium was used with a blood volume of 1.5 mL for the first 23 months, and the BacT/Alert PF paediatric medium was used with a 0.5-mL volume for the remaining 18 months. The isolation rates were similar during both periods (13.4% vs. 13.1%), and staphylococci were the most common isolates (72.8%). There was a shorter time to detection of staphylococci with the smaller-volume (PF) procedure, which thus seems suitable for use in the diagnosis of staphylococcal bacteraemia in the PICU.

Developmental changes of optical properties in neonates determined by near-infrared time-resolved spectroscopy

Near-infrared spectroscopy has been used for measurement of changes in cerebral Hb concentrations in infants to study cerebral oxygenation and hemodynamics. In this study, measurements by time-resolved spectroscopy (TRS) were performed in 22 neonates to estimate the values of light absorption coefficient and reduced scattering coefficient (mu'(s)), cerebral Hb oxygen saturation (SCO2), cerebral blood volume (CBV), and differential pathlength factor (DPF), and the relationships between postconceptional age and mu'(s), SCO2, CBV, and DPF were investigated. A portable three-wavelength TRS system with a probe attached to the head of the neonate was used. The mean mu'(s) values at 761, 795, and 835 nm in neonates were estimated to be (mean +/- SD) 6.46 +/- 1.21, 5.90 +/- 1.15 and 6.40 +/- 1.16/cm, respectively. There was a significant positive relationship between postconceptional age and mu'(s) at those three wavelengths. The mean SCO2 value was calculated to be 70.0 +/- 4.6%, and postconceptional age and SCO2 showed a negative linear relationship. The mean value of CBV was 2.31 +/- 0.56 mL/100 g. There was a significant positive relationship between postconceptional age and CBV. The mean DPF values at 761, 795, and 835 nm were estimated to be 4.58 +/- 0.41, 4.64 +/- 0.46, and 4.31 +/- 0.42, respectively. There was no relationship between postconceptional age and DPF at those three wavelengths. The results demonstrated that our near-infrared TRS method can be used to monitor mu'(s), SCO2, CBV, and DPF in the neonatal brain at the bedside in an intensive care unit.

Estimation of circulating blood volume in infants using the pulse dye densitometry method

BACKGROUND

Estimation of hemodynamics is important for critically ill infants. Pulse dye densitometry (PDD) using indocyanine green (ICG), which enables measurements of circulating blood volume at the bedside, has recently been developed for adults.

METHODS

We conducted a basic investigation to determine whether this method can be applied to infants and measured circulating blood volume in 25 infants whose gestational ages ranged from 24 to 40 weeks (median, 32 weeks). At first, to validate the accuracy of measurements, arterial ICG concentrations determined by blood sample measurements were compared using a spectrophotometer ([ICG blood]) and by noninvasive measurement using PDD ([ICG pdd]) in seven infants. Next, blood volumes in 25 infants were estimated by the PDD method.

RESULTS

There was a positive relationships between [ICG blood] and [ICG pdd] (r = 0.913, P < 0.0001). Using Bland Altman analysis, the bias between the two methods was 0.24 +/- 0.30 mg.l(-1) (95% confidence interval: 0.39-0.09 mg.l(-1)) and the limits of agreement (2 sd) were -0.36 and 0.84 mg.l(-1), respectively. Mean (sd) blood volume was 94.9 ml.kg(-1) (24.3). The values obtained by this study are almost the same as previously reported values obtained by using other methods.

CONCLUSIONS

PDD using ICG can be used to monitor of hemodynamics in infants.

Near infrared spectroscopy in brain injury: today’s perspective

The technique of near infrared spectroscopy (NIRS) is based on the principle of light attenuation by the chromophores oxyhaemoglobin (HbO2), deoxyhaemoglobin (Hb) and cytochrome oxidase. Changes in the detected light levels can therefore represent changes in concentrations of these chromophores. Clinical use of NIRS in the brain has been well established in neonates where transillumination is possible. While it has become a useful research tool for monitoring the adult brain, clinical application has been hampered by the fact that it must be applied in reflectance mode. This has resulted in a number of concerns, most significantly the issue of signal contamination by the extracranial tissue layers. Algorithms have been applied to try to overcome this problem, and techniques such as time resolved, phase resolved and spatially resolved spectroscopy have been developed. There has been renewed interest in NIRS as an easy to use, non-invasive technique for measuring tissue oxygenation in the adult brain. Recent technical advances have led to the development of compact, portable instruments that detect changes in optical attenuation of several wavelengths of light. Near infrared spectroscopy is an evolving technology that holds significant potential for technical advancement. In particular, NIRS shows future promise as a clinical tool for bedside cerebral blood flow measurements and as a cerebral imaging modality for mapping structure and function.