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Beqiri E, Placek MM, Chu KH, Donnelly J, Cucciolini G, Motroni V, Smith CA, Czosnyka M, Hutchinson P, Smielewski P. Exploration of uncertainty of PRx time trends. Brain Spine 2024; 4:102795. [PMID: 38601774 PMCID: PMC11004690 DOI: 10.1016/j.bas.2024.102795] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/29/2023] [Revised: 03/26/2024] [Accepted: 03/30/2024] [Indexed: 04/12/2024]
Abstract
Introduction PRx can be used as surrogate measure of Cerebral Autoregulation (CA) in traumatic brain injury (TBI) patients. PRx can provide means for individualising cerebral perfusion pressure (CPP) targets, such as CPPopt. However, a recent Delphi consensus of clinicians concluded that consensus could not be reached on the accuracy, reliability, and validation of any current CA assessment method. Research question We aimed to quantify the short-term uncertainty of PRx time-trends and to relate this to other physiological measurements. Material and methods Intracranial pressure (ICP), arterial blood pressure (ABP), end-tidal CO2 (EtCO2) high-resolution recordings of 911 TBI patients were processed with ICM + software. Hourly values of metrics that describe the variability within modalities derived from ABP, ICP and EtCO2, were calculated for the first 24h of neuromonitoring. Generalized additive models were used to describe the time trend of the variability in PRx. Linear correlations were studied for describing the relationship between PRx variability and the other physiological modalities. Results The time profile of variability of PRx decreases over the first 12h and was higher for average PRx ∼0. Increased variability of PRx was not linearly linked with average ABP, ICP, or CPP. For coherence between slow waves of ABP and ICP >0.7, the variability in PRx decreased (R = -0.47, p < 0.001). Discussion and conclusion PRx is a highly variable parameter. PRx short-term dispersion was not related to average ICP, ABP or CPP. The determinants of uncertainty of PRx should be investigated to improve reliability of individualised CA assessment in TBI patients.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Michal M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
- Neurosurgery Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Ka Hing Chu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
- Department of Medicine, University of Auckland, New Zealand
| | - Giada Cucciolini
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
- Neurosurgery Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
- Department of Medicine, University of Auckland, New Zealand
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Virginia Motroni
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Claudia A. Smith
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
| | - Peter Hutchinson
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
- Neurosurgery Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, United Kingdom
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Beqiri E, Czosnyka M, Placek MM, Cucciolini G, Motroni V, Smith CA, Hutchinson P, Smielewski P. Red solid line: Patterns of terminal loss of cerebrovascular reactivity at the bedside. Brain Spine 2024; 4:102760. [PMID: 38510604 PMCID: PMC10951796 DOI: 10.1016/j.bas.2024.102760] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 01/17/2024] [Accepted: 01/21/2024] [Indexed: 03/22/2024]
Abstract
Introduction Continuous monitoring of the pressure reactivity index (PRx) provides an estimation of dynamic cerebral autoregulation (CA) at the bedside in traumatic brain injury (TBI) patients. Visualising the time-trend of PRx with a risk bar chart in ICM + software at the bedside allows for better real-time interpretability of the autoregulation status. When PRx>0.3 is sustained for long periods, typically of at least half an hour, the bar shows a pattern called "red solid line" (RSL). RSL was previously described to precede refractory intracranial hypertension and brain death. Research question We aimed to describe pathophysiological changes in measured signals/parameters during RSL. Material and methods Observation of time-trends of PRx, intracranial pressure, cerebral perfusion pressure, brain oxygenation and compensatory reserve of TBI patients with RSL. Results Three pathophysiological patterns were identified: RSL precedes intracranial hypertension, RSL is preceded by intracranial hypertension, or RSL is preceded by brain hypoperfusion. In all cases, RSL was followed by death and the RSL onset was between 1 h and 1 day before the terminal event. Discussion and conclusion RSL precedes death in intensive care and could represent a marker for terminal clinical deterioration in TBI patients. These findings warrant further investigations in larger cohorts to characterise pathophysiological mechanisms underlying the RSL pattern and whether RSL has a significant relationship with outcome after TBI.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Michal M. Placek
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Neurosurgery Department, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Giada Cucciolini
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Virginia Motroni
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
- Department of Surgical, Medical, Molecular Pathology and Critical Care Medicine, University of Pisa, Italy
| | - Claudia A. Smith
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Hutchinson
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
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Czosnyka Z, Lalou A, Pelah AI, Joanides AJ, Smielewski P, Placek MM, Marek C. Cerebral hemodynamic monitoring combined with infusion test in hydrocephalus. Brain Spine 2023; 3:102705. [PMID: 38021025 PMCID: PMC10668090 DOI: 10.1016/j.bas.2023.102705] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 06/30/2023] [Revised: 10/14/2023] [Accepted: 10/29/2023] [Indexed: 12/01/2023]
Abstract
Introduction Disturbance in cerebrospinal fluid (CSF) circulation may overlap with abnormality of cerebral blood flow (CBF) in hydrocephalus. Transcranial Doppler (TCD) ultrasonography is a non-invasive technique able to assess CBF velocity (CBFv) dynamics in response to a controlled rise in ICP during CSF infusion tests. Research question Which TCD-derived cerebral hemodynamic parameters change during controlled rise of ICP, and in which direction? Material and methods Infusion tests combined with TCD monitoring and non-invasive monitoring of arterial blood pressure (ABP) were conducted in 65 hydrocephalic patients. TCD-based hemodynamic variables: spectral pulsatility index (sPI), compliance of CSF space (Ci), cerebral autoregulation index (Mx), critical closing pressure (CrCP), cerebrovascular wall tension (WT) and diastolic closing margin (DCM-distance between diastolic ABP and CrCP) were calculated retrospectively. Results During the test ICP increased on average to 25 mm Hg (p < 0.0001), with a parallel decrease in cerebral perfusion pressure (CPP, p < 0.0003). The CBFv waveform changed, showing a rise in sPI (p < 0.0001). Ci decreased inversely proportional to a rise in ICP, and correlated well with changes of compliance calculated from the Marmarou model. CrCP increased in response to rising ICP (p < 0.001) while WT decreased (p < 0.002). DCM correlated with cerebrospinal elasticity (R = -0.31; p < 0.04). Cerebral autoregulation was worse in patients with normal CSF circulation, measured as resistance to CSF outflow (Rout): Pearson correlation between Mx and Rout was R = -0.41; p < 0.02. Conclusion A controlled rise in ICP affects cerebral hemodynamics in a moderate manner. Parameters like cerebral autoregulation index or DCM correlate with CSF dynamics and may be considered as supplementary variables for the diagnosis of hydrocephalus.
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Affiliation(s)
- Zofia Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Afroditi Lalou
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Adam I. Pelah
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Alexis J. Joanides
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Michal M. Placek
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
| | - Czosnyka Marek
- Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, UK
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Zoerle T, Birg T, Carbonara M, Smielewski P, Placek MM, Zanier ER, Åkerlund CAI, Ortolano F, Stocchetti N. Accuracy of Manual Intracranial Pressure Recording Compared to a Computerized High-Resolution System: A CENTER-TBI Analysis. Neurocrit Care 2023; 38:781-790. [PMID: 36922475 PMCID: PMC10241732 DOI: 10.1007/s12028-023-01697-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2022] [Accepted: 02/09/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND Monitoring intracranial pressure (ICP) and cerebral perfusion pressure (CPP) is crucial in the management of the patient with severe traumatic brain injury (TBI). In several institutions ICP and CPP are summarized hourly and entered manually on bedside charts; these data have been used in large observational and interventional trials. However, ICP and CPP may change rapidly and frequently, so data recorded in medical charts might underestimate actual ICP and CPP shifts. The aim of this study was to evaluate the accuracy of manual data annotation for proper capturing of ICP and CPP. For this aim, we (1) compared end-hour ICP and CPP values manually recorded (MR) with values recorded continuously by computerized high-resolution (HR) systems and (2) analyzed whether MR ICP and MR CPP are reliable indicators of the burden of intracranial hypertension and low CPP. METHODS One hundred patients were included. First, we compared the MR data with the values stored in the computerized system during the first 7 days after admission. For this point-to-point analysis, we calculated the difference between end-hour MR and HR ICP and CPP. Then we analyzed the burden of high ICP (> 20 mm Hg) and low CPP (< 60 mm Hg) measured by the computerized system, in which continuous data were stored, compared with the pressure-time dose based on end-hour measurements. RESULTS The mean difference between MR and HR end-hour values was 0.02 mm Hg for ICP (SD 3.86 mm Hg) and 1.54 mm Hg for CPP (SD 8.81 mm Hg). ICP > 20 mm Hg and CPP < 60 mm Hg were not detected by MR in 1.6% and 5.8% of synchronized measurements, respectively. Analysis of the pathological ICP and CPP throughout the recording, however, indicated that calculations based on manual recording seriously underestimated the ICP and CPP burden (in 42% and 28% of patients, respectively). CONCLUSIONS Manual entries fairly represent end-hour HR ICP and CPP. However, compared with a computerized system, they may prove inadequate, with a serious risk of underestimation of the ICP and CPP burden.
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Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Tatiana Birg
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Elisa R Zanier
- Department of Neuroscience, Istituto di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Beqiri E, Zeiler FA, Ercole A, Placek MM, Tas J, Donnelly J, Aries MJH, Hutchinson PJ, Menon D, Stocchetti N, Czosnyka M, Smielewski P. The lower limit of reactivity as a potential individualised cerebral perfusion pressure target in traumatic brain injury: a CENTER-TBI high-resolution sub-study analysis. Crit Care 2023; 27:194. [PMID: 37210526 PMCID: PMC10199598 DOI: 10.1186/s13054-023-04485-8] [Citation(s) in RCA: 10] [Impact Index Per Article: 10.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 05/11/2023] [Indexed: 05/22/2023] Open
Abstract
BACKGROUND A previous retrospective single-centre study suggested that the percentage of time spent with cerebral perfusion pressure (CPP) below the individual lower limit of reactivity (LLR) is associated with mortality in traumatic brain injury (TBI) patients. We aim to validate this in a large multicentre cohort. METHODS Recordings from 171 TBI patients from the high-resolution cohort of the CENTER-TBI study were processed with ICM+ software. We derived LLR as a time trend of CPP at a level for which the pressure reactivity index (PRx) indicates impaired cerebrovascular reactivity with low CPP. The relationship with mortality was assessed with Mann-U test (first 7-day period), Kruskal-Wallis (daily analysis for 7 days), univariate and multivariate logistic regression models. AUCs (CI 95%) were calculated and compared using DeLong's test. RESULTS Average LLR over the first 7 days was above 60 mmHg in 48% of patients. %time with CPP < LLR could predict mortality (AUC 0.73, p = < 0.001). This association becomes significant starting from the third day post injury. The relationship was maintained when correcting for IMPACT covariates or for high ICP. CONCLUSIONS Using a multicentre cohort, we confirmed that CPP below LLR was associated with mortality during the first seven days post injury.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Frederick A Zeiler
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
- Department of Clinical Neuroscience, Karolinska Intitutet, Stockholm, Sweden
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Marcel J H Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital and University of Cambridge, Cambridge, CB2 0QQ, UK
| | - David Menon
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anaesthesia and Critical Care, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Beqiri E, Ercole A, Aries MJH, Placek MM, Tas J, Czosnyka M, Stocchetti N, Smielewski P. Towards autoregulation-oriented management after traumatic brain injury: increasing the reliability and stability of the CPPopt algorithm. J Clin Monit Comput 2023:10.1007/s10877-023-01009-1. [PMID: 37119323 PMCID: PMC10371880 DOI: 10.1007/s10877-023-01009-1] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/23/2023] [Accepted: 04/01/2023] [Indexed: 05/01/2023]
Abstract
PURPOSE CPPopt denotes a Cerebral Perfusion Pressure (CPP) value at which the Pressure-Reactivity index, reflecting the global state of Cerebral Autoregulation, is best preserved. CPPopt has been investigated as a potential dynamically individualised CPP target in traumatic brain injury patients admitted in intensive care unit. The prospective bedside use of the concept requires ensured safety and reliability of the CPP recommended targets based on the automatically-generated CPPopt. We aimed to: Increase stability and reliability of the CPPopt automated algorithm by fine-tuning; perform outcome validation of the adjusted algorithm in a multi-centre TBI cohort. METHODS ICM + software was used to derive CPPopt and fine-tune the algorithm. Parameters for improvement of the algorithm were selected based on qualitative and quantitative assessment of stability and reliability metrics. Patients enrolled in the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution cohort were included for retrospective validation. Yield and stability of the new algorithm were compared to the previous algorithm using Mann-U test. Area under the curves for mortality prediction at 6 months were compared with the DeLong Test. RESULTS CPPopt showed higher stability (p < 0.0001), but lower yield compared to the previous algorithm [80.5% (70-87.5) vs 85% (75.7-91.2), p < 0.001]. Deviation of CPPopt could predict mortality with an AUC of [AUC = 0.69 (95% CI 0.59-0.78), p < 0.001] and was comparable with the previous algorithm. CONCLUSION The CPPopt calculation algorithm was fine-tuned and adapted for prospective use with acceptable lower yield, improved stability and maintained prognostic power.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Ari Ercole
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Marcel J H Aries
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Jeanette Tas
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
- School of Mental Health and Neurosciences, Maastricht University, Maastricht, The Netherlands
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Nino Stocchetti
- Department of Anaesthesia and Critical Care, Neuroscience Intensive Care Unit, Fondazione IRCCS Ca' Granda-Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplants, University of Milan, Milan, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Zoerle T, Birg T, Carbonara M, Smielewski P, Placek MM, Zanier ER, Åkerlund CAI, Ortolano F, Stocchetti N. Correction: Accuracy of Manual Intracranial Pressure Recording Compared to a Computerized High-Resolution System: A CENTER-TBI Analysis. Neurocrit Care 2023:10.1007/s12028-023-01722-4. [PMID: 37059959 DOI: 10.1007/s12028-023-01722-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/16/2023]
Affiliation(s)
- Tommaso Zoerle
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy.
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy.
| | - Tatiana Birg
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Marco Carbonara
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Peter Smielewski
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Lab, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Elisa R Zanier
- Department of Neuroscience, Istituto Di Ricerche Farmacologiche Mario Negri IRCCS, Milan, Italy
| | - Cecilia A I Åkerlund
- Department of Physiology and Pharmacology, Section of Perioperative Medicine and Intensive Care, Karolinska Institutet, Stockholm, Sweden
| | - Fabrizio Ortolano
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
| | - Nino Stocchetti
- Neuroscience Intensive Care Unit, Department of Anesthesia and Critical Care, Fondazione IRCCS Ca' Granda Ospedale Maggiore Policlinico, Milan, Italy
- Department of Pathophysiology and Transplantation, University of Milan, Milan, Italy
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Agrawal S, Placek MM, White D, Daubney E, Cabeleira M, Smielewski P, Czosnyka M, Young A, Watson S, Maw A, Hutchinson PJ. Studying Trends of Auto-Regulation in Severe Head Injury in Paediatrics (STARSHIP): protocol to study cerebral autoregulation in a prospective multicentre observational research database study. BMJ Open 2023; 13:e071800. [PMID: 36898758 PMCID: PMC10008199 DOI: 10.1136/bmjopen-2023-071800] [Citation(s) in RCA: 5] [Impact Index Per Article: 5.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 03/12/2023] Open
Abstract
INTRODUCTION Studying cerebral autoregulation, particularly PRx (Pressure Reactivity Index), is commonly employed in adult traumatic brain injury (TBI) and gives real-time information about intracranial pathophysiology, which can help in patient management. Experience in paediatric TBI (PTBI) is limited to single-centre studies despite disproportionately higher incidence of morbidity and mortality in PTBI than in adult TBI. PROJECT We describe the protocol to study cerebral autoregulation using PRx in PTBI. The project called Studying Trends of Auto-Regulation in Severe Head Injury in Paediatrics is a multicentre prospective ethics approved research database study from 10 centres across the UK. Recruitment started in July 2018 with financial support from local/national charities (Action Medical Research for Children, UK). METHODS AND ANALYSIS The first phase of the project is powered to detect optimal thresholds of PRx associated with favourable outcome in PTBI by recruiting 135 patients (initial target of 3 years which has changed to 5 years due to delays related to COVID-19 pandemic) from 10 centres in the UK with outcome follow-up to 1-year postictus. The secondary objectives are to characterise patterns of optimal cerebral perfusion pressure in PTBI and compare the fluctuations in these measured parameters with outcome. The goal is to create a comprehensive research database of a basic set of high-resolution (full waveforms resolution) neuromonitoring data in PTBI for scientific use. ETHICS AND DISSEMINATION Favourable ethical approval has been provided by Health Research Authority, Southwest-Central Bristol Research Ethics Committee (Ref: 18/SW/0053). Results will be disseminated via publications in peer-reviewed medical journals and presentations at national and international conferences. TRIAL REGISTRATION NUMBER NCT05688462.
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Affiliation(s)
- Shruti Agrawal
- Department of Paediatrics, Cambridge University, Cambridge, UK
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Michal M Placek
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Deborah White
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Esther Daubney
- Paediatric Intensive Care, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Manuel Cabeleira
- Department of Mechanical Engineering, University College London, London, UK
| | - Peter Smielewski
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Department of Paediatrics, Cambridge University, Cambridge, UK
| | - Adam Young
- Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Suzanna Watson
- Paediatric Neuropsychology, Cambridge Centre for Paediatric Neuropsychological Rehabilitation, Cambridge, UK
- Centre for Child Development, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
| | - Anna Maw
- Paediatric Neurologi, Cambridge University Hospitals NHS Foundation Trust, Cambridge, UK
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Dimitri GM, Beqiri E, Placek MM, Czosnyka M, Stocchetti N, Ercole A, Smielewski P, Lió P. Modeling Brain-Heart Crosstalk Information in Patients with Traumatic Brain Injury. Neurocrit Care 2021; 36:738-750. [PMID: 34642842 PMCID: PMC9110542 DOI: 10.1007/s12028-021-01353-7] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/13/2020] [Accepted: 09/09/2021] [Indexed: 11/28/2022]
Abstract
Background Traumatic brain injury (TBI) is an extremely heterogeneous and complex pathology that requires the integration of different physiological measurements for the optimal understanding and clinical management of patients. Information derived from intracranial pressure (ICP) monitoring can be coupled with information obtained from heart rate (HR) monitoring to assess the interplay between brain and heart. The goal of our study is to investigate events of simultaneous increases in HR and ICP and their relationship with patient mortality.. Methods In our previous work, we introduced a novel measure of brain–heart interaction termed brain–heart crosstalks (ctnp), as well as two additional brain–heart crosstalks indicators [mutual information (\documentclass[12pt]{minimal}
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\begin{document}$$mi_{ct}$$\end{document}mict) and average edge overlap (ωct)] obtained through a complex network modeling of the brain–heart system. These measures are based on identification of simultaneous increase of HR and ICP. In this article, we investigated the relationship of these novel indicators with respect to mortality in a multicenter TBI cohort, as part of the Collaborative European Neurotrauma Effectiveness Research in TBI high-resolution work package. Results A total of 226 patients with TBI were included in this cohort. The data set included monitored parameters (ICP and HR), as well as laboratory, demographics, and clinical information. The number of detected brain–heart crosstalks varied (mean 58, standard deviation 57). The Kruskal–Wallis test comparing brain–heart crosstalks measures of survivors and nonsurvivors showed statistically significant differences between the two distributions (p values: 0.02 for \documentclass[12pt]{minimal}
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\begin{document}$$mi_{ct}$$\end{document}mict, 0.005 for ctnp and 0.006 for ωct). An inverse correlation was found, computed using the point biserial correlation technique, between the three new measures and mortality: − 0.13 for ctnp (p value 0.04), − 0.19 for ωct (p value 0.002969) and − 0.09 for \documentclass[12pt]{minimal}
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\begin{document}$$mi_{ct}$$\end{document}mict (p value 0.1396). The measures were then introduced into the logistic regression framework, along with a set of input predictors made of clinical, demographic, computed tomography (CT), and lab variables. The prediction models were obtained by dividing the original cohort into four age groups (16–29, 30–49, 50–65, and 65–85 years of age) to properly treat with the age confounding factor. The best performing models were for age groups 16–29, 50–65, and 65–85, with the deviance of ratio explaining more than 80% in all the three cases. The presence of an inverse relationship between brain–heart crosstalks and mortality was also confirmed. Conclusions The presence of a negative relationship between mortality and brain–heart crosstalks indicators suggests that a healthy brain–cardiovascular interaction plays a role in TBI.
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Affiliation(s)
- Giovanna Maria Dimitri
- Computer Laboratory, University of Cambridge, Cambridge, UK. .,DIISM, University of Siena, Siena, Italy.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.,Faculty of Fundamental Problems of Technology, Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wrocław, Poland
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Nino Stocchetti
- Department of Physiology and Transplantation, University of Milan, Milan, Italy
| | - Ari Ercole
- Division of Anesthesia, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Pietro Lió
- Computer Laboratory, University of Cambridge, Cambridge, UK
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10
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Khan DZ, Placek MM, Smielewski P, Budohoski KP, Anwar F, Hutchinson PJA, Bance M, Czosnyka M, Helmy A. 817 Robotic Semi-Automated Transcranial Doppler Assessment of Cerebrovascular Autoregulation in Post Concussional Syndrome: Methodological Considerations. Br J Surg 2021. [DOI: 10.1093/bjs/znab135.003] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022]
Abstract
Abstract
Introduction
Post-concussive syndrome (PCS) refers to a constellation of physical, cognitive, and emotional symptoms after traumatic brain injury (TBI). Despite its incidence, the underlying mechanisms are unclear. We hypothesised that impaired cerebral autoregulation (CA) is a contributor.
Method
A prospective, observational study was integrated into outpatient clinics at a tertiary neurosurgical centre. Data points included: demographics, symptoms (Post-Concussion Symptom Scale [PCSS]), neuropsychological assessment (Cambridge Neuropsychological Test Automated-Battery [CANTAB]) and cerebrovascular metrics (Mxa co-efficient and the transient hyperaemic-response ratio [THRR]) - via transcranial Doppler (TCD), plethysmography and bespoke software (ICM+).
Results
12 participants were recruited with 2 excluded after unsuccessful cerebrovascular TCD insonation. 10 participants (5 TBI patients, 5 healthy controls) were included in the analysis (median age 26.5, male:female 7:3). Median PCSS scores were 6/126 (TBI subgroup). Median CANTAB percentiles were 78 (healthy controls) and 25 (TBI). Mxa was calculated for 90% and THRR for 50% of participants. Median study time was 127.5 minutes and feedback (n = 6) highlighted the perceived acceptability of the study.
Conclusions
This pilot study has demonstrated a feasible and reproducible assessment of PCS and CA metrics (non-invasively) in a real-world setting. By scaling this methodology, we hope to test whether CA changes are correlated with symptomatic PCS in patients post-TBI.
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Affiliation(s)
- D Z Khan
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - M M Placek
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - P Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - K P Budohoski
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - F Anwar
- Department of Neurorehabilitation, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - P J A Hutchinson
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - M Bance
- Department of ENT, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - M Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - A Helmy
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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11
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Lalou AD, Czosnyka M, Placek MM, Smielewski P, Nabbanja E, Czosnyka Z. CSF Dynamics for Shunt Prognostication and Revision in Normal Pressure Hydrocephalus. J Clin Med 2021; 10:jcm10081711. [PMID: 33921142 PMCID: PMC8071572 DOI: 10.3390/jcm10081711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the quantitative information derived from testing of the CSF circulation, there is still no consensus on what the best approach could be in defining criteria for shunting and predicting response to CSF diversion in normal pressure hydrocephalus (NPH). OBJECTIVE We aimed to review the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We have focused on reporting the objective perspective of CSF dynamics testing, without further inferences to individual patient management. DISCUSSION No single parameter from the CSF infusion study has so far been able to serve as an unquestionable outcome predictor. Resistance to CSF outflow (Rout) is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. Testing of CSF dynamics provides information on hydrodynamic properties of the cerebrospinal compartment: the system which is being modified by a shunt. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the relationship between CSF circulation testing and clinical improvement. CONCLUSIONS Despite many open questions and limitations, testing of CSF dynamics provides unique perspectives for the clinician. We have found value in understanding shunt function and potentially shunt response through shunt testing in vivo. In the absence of infusion tests, further methods that provide a clear description of the pre and post-shunting CSF circulation, and potentially cerebral blood flow, should be developed and adapted to the bed-space.
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Affiliation(s)
- Afroditi Despina Lalou
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Correspondence: ; Tel.: +44-774-3567-585
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Institute of Electronic Systems, Faculty of Electronics and Information Sciences, Warsaw University of Technology, 00-661 Warsaw, Poland
| | - Michal M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Eva Nabbanja
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
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12
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Papaioannou VE, Budohoski KP, Placek MM, Czosnyka Z, Smielewski P, Czosnyka M. Association of transcranial Doppler blood flow velocity slow waves with delayed cerebral ischemia in patients suffering from subarachnoid hemorrhage: a retrospective study. Intensive Care Med Exp 2021; 9:11. [PMID: 33768351 PMCID: PMC7994457 DOI: 10.1186/s40635-021-00378-8] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/04/2020] [Accepted: 02/17/2021] [Indexed: 11/25/2022] Open
Abstract
Background Cerebral vasospasm (VS) and delayed cerebral ischemia (DCI) constitute major complications following subarachnoid hemorrhage (SAH). A few studies have examined the relationship between different indices of cerebrovascular dynamics with the occurrence of VS. However, their potential association with the development of DCI remains elusive. In this study, we investigated the pattern of changes of different transcranial Doppler (TCD)-derived indices of cerebrovascular dynamics during vasospasm in patients suffering from subarachnoid hemorrhage, dichotomized by the presence of delayed cerebral ischemia. Methods A retrospective analysis was performed using recordings from 32 SAH patients, diagnosed with VS. Patients were divided in two groups, depending on development of DCI. Magnitude of slow waves (SWs) of cerebral blood flow velocity (CBFV) was measured. Cerebral autoregulation was estimated using the moving correlation coefficient Mxa. Cerebral arterial time constant (tau) was expressed as the product of resistance and compliance. Complexity of CBFV was estimated through measurement of sample entropy (SampEn). Results In the whole population (N = 32), magnitude of SWs of ipsilateral to VS side CBFV was higher during vasospasm (4.15 ± 1.55 vs before: 2.86 ± 1.21 cm/s, p < 0.001). Ipsilateral SWs of CBFV before VS had higher magnitude in DCI group (N = 19, p < 0.001) and were strongly predictive of DCI, with area under the curve (AUC) = 0.745 (p = 0.02). Vasospasm caused a non-significant shortening of ipsilateral values of tau and increase in SampEn in all patients related to pre-VS measurements, as well as an insignificant increase of Mxa in DCI related to non-DCI group (N = 13). Conclusions In patients suffering from subarachnoid hemorrhage, TCD-detected VS was associated with higher ipsilateral CBFV SWs, related to pre-VS measurements. Higher CBFV SWs before VS were significantly predictive of delayed cerebral ischemia.
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Affiliation(s)
- Vasilios E Papaioannou
- Department of Intensive Care Medicine, Alexandroupolis Hospital, Democritus University of Thrace, 68100, Alexandoupolis, Greece. .,Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, Box 167, Cambridge, CB20QQ, UK.
| | - Karol P Budohoski
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, Box 167, Cambridge, CB20QQ, UK.,Department of Neurosurgery, Cambridge University Hospitals, Cambridge, CB20QQ, UK
| | - Michal M Placek
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, Box 167, Cambridge, CB20QQ, UK.,Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wrocław University of Science and Technology, 50-370, Wrocław, Poland
| | - Zofia Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, Box 167, Cambridge, CB20QQ, UK
| | - Peter Smielewski
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, Box 167, Cambridge, CB20QQ, UK
| | - Marek Czosnyka
- Academic Neurosurgery Unit, Brain Physics Lab, Addenbrooke's Hospital, Box 167, Cambridge, CB20QQ, UK
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13
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Khan DZ, Placek MM, Smielewski P, Budohoski KP, Anwar F, Hutchinson PJA, Bance M, Czosnyka M, Helmy A. Robotic Semi-Automated Transcranial Doppler Assessment of Cerebrovascular Autoregulation in Post-Concussion Syndrome: Methodological Considerations. Neurotrauma Rep 2020; 1:218-231. [PMID: 33274347 PMCID: PMC7703686 DOI: 10.1089/neur.2020.0021] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/02/2023] Open
Abstract
Post-concussion syndrome (PCS) refers to a constellation of physical, cognitive, and emotional symptoms after traumatic brain injury (TBI). Despite its incidence and impact, the underlying mechanisms of PCS are unclear. We hypothesized that impaired cerebral autoregulation (CA) is a contributor. In this article, we present our protocol for non-invasively assessing CA in patients with TBI and PCS in a real-world clinical setting. A prospective, observational study was integrated into outpatient clinics at a tertiary neurosurgical center. Data points included: demographics, symptom profile (Post-Concussion Symptom Scale [PCSS]) and neuropsychological assessment (Cambridge Neuropsychological Test Automated-Battery [CANTAB]). Cerebrovascular metrics (nMxa co-efficient and the transient hyperaemic-response ratio [THRR]) were collected using transcranial Doppler (TCD), finger plethysmography, and bespoke software (ICM+). Twelve participants were initially recruited but 2 were excluded after unsuccessful insonation of the middle cerebral artery (MCA); 10 participants (5 patients with TBI, 5 healthy controls) were included in the analysis (median age 26.5 years, male to female ratio: 7:3). Median PCSS scores were 6/126 for the TBI patient sub-groups. Median CANTAB percentiles were 78 (healthy controls) and 25 (TBI). nMxa was calculated for 90% of included patients, whereas THRR was calculated for 50%. Median study time was 127.5 min and feedback (n = 6) highlighted the perceived acceptability of the study. This pilot study has demonstrated a reproducible assessment of PCS and CA metrics (non-invasively) in a real-world setting. This protocol is feasible and is acceptable to participants. By scaling this methodology, we hope to test whether CA changes are correlated with symptomatic PCS in patients post-TBI.
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Affiliation(s)
- Danyal Z Khan
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Michal M Placek
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom
| | - Karol P Budohoski
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Fahim Anwar
- Department of Neurorehabilitation, Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Peter J A Hutchinson
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Manohar Bance
- Department of ENT, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Department of Clinical Neurosciences, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Adel Helmy
- Division of Neurosurgery, University of Cambridge and Cambridge University Hospitals NHS Foundation Trust, Cambridge, United Kingdom
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14
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Zeiler FA, Ercole A, Placek MM, Hutchinson PJ, Stocchetti N, Czosnyka M, Smielewski P. Association between Physiological Signal Complexity and Outcomes in Moderate and Severe Traumatic Brain Injury: A CENTER-TBI Exploratory Analysis of Multi-Scale Entropy. J Neurotrauma 2020; 38:272-282. [PMID: 32814492 DOI: 10.1089/neu.2020.7249] [Citation(s) in RCA: 10] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/11/2023] Open
Abstract
In traumatic brain injury (TBI), preliminary retrospective work on signal entropy suggests an association with global outcome. The goal of this study was to provide multi-center validation of the association between multi-scale entropy (MSE) of cardiovascular and cerebral physiological signals, with six-month outcome. Using the Collaborative European NeuroTrauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we selected patients with a minimum of 72 h of physiological recordings and a documented six-month Glasgow Outcome Scale Extended (GOSE) score. The 10-sec summary data for heart rate (HR), mean arterial pressure (MAP), intracranial pressure (ICP), and pulse amplitude of ICP (AMP) were derived across the first 72 h of data. The MSE complexity index (MSE-Ci) was determined for HR, MAP, ICP, and AMP, with the association between MSE and dichotomized six-month outcomes assessed using Mann-Whitney U testing and logistic regression analysis. A total of 160 patients had a minimum of 72 h of recording and a documented outcome. Decreased HR MSE-Ci (7.3 [interquartile range (IQR) 5.4 to 10.2] vs. 5.1 [IQR 3.1 to 7.0]; p = 0.002), lower ICP MSE-Ci (11.2 [IQR 7.5 to 14.2] vs. 7.3 [IQR 6.1 to 11.0]; p = 0.009), and lower AMP MSE-Ci (10.9 [IQR 8.0 to 13.7] vs. 8.7 [IQR 6.6 to 11.0]; p = 0.022), were associated with death. Similarly, lower HR MSE-Ci (8.0 [IQR 6.2 to 10.9] vs. 6.2 [IQR 3.9 to 8.7]; p = 0.003) and lower ICP MSE-Ci (11.4 [IQR 8.6 to 14.4)] vs. 9.2 [IQR 6.0 to 13.5]), were associated with unfavorable outcome. Logistic regression analysis confirmed that lower HR MSE-Ci and ICP MSE-Ci were associated with death and unfavorable outcome at six months. These findings suggest that a reduction in cardiovascular and cerebrovascular system entropy is associated with worse outcomes. Further work in the field of signal complexity in TBI multi-modal monitoring is required.
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Affiliation(s)
- Frederick A Zeiler
- Division of Anaesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Department of Surgery, and Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada.,Biomedical Engineering, Faculty of Engineering, and University of Manitoba, Winnipeg, Manitoba, Canada.,Centre on Aging, University of Manitoba, Winnipeg, Manitoba, Canada
| | - Ari Ercole
- Division of Anaesthesia, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Michal M Placek
- Department of Biomedical Engineering, Faculty of Fundamental Problems of Technology, Wroclaw University of Science and Technology, Wroclaw, Poland.,Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J Hutchinson
- Department of Clinical Neurosciences, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Nino Stocchetti
- Neuro ICU Fondazione IRCCS Cà Granda Ospedale Maggiore Policlinico, Milan, Italy.,Department of Physiopathology and Transplantation, Milan University, Milan, Italy
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom.,Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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15
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Sortica da Costa C, Placek MM, Czosnyka M, Cabella B, Kasprowicz M, Austin T, Smielewski P. Complexity of brain signals is associated with outcome in preterm infants. J Cereb Blood Flow Metab 2017; 37:3368-3379. [PMID: 28075691 PMCID: PMC5624386 DOI: 10.1177/0271678x16687314] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
A characteristic feature of complex healthy biological systems is the ability to react and adapt to minute changes in the environment. This 'complexity' manifests itself in highly irregular patterns of various physiological measurements. Here, we apply Multiscale Entropy (MSE) analysis to assess the complexity of systemic and cerebral near-infrared spectroscopy (NIRS) signals in a cohort of 61 critically ill preterm infants born at median (range) gestational age of 26 (23-31) weeks, before 24 h of life. We further correlate the complexity of these parameters with brain injury and mortality. Lower complexity index (CoI) of oxygenated haemoglobin (HbO2), deoxygenated haemoglobin (Hb) and tissue oxygenation index (TOI) were observed in those infants who developed intraventricular haemorrhage (IVH) compared to those who did not (P = 0.002, P = 0.010 and P = 0.038, respectively). Mean CoI of HbO2, Hb and total haemoglobin index (THI) were lower in those infants who died compared to those who survived (P = 0.012, P = 0.004 and P = 0.003, respectively). CoI-HbO2 was an independent predictor of IVH (P = 0.010). Decreased complexity of brain signals was associated with mortality and brain injury. Measurement of brain signal complexity in preterm infants is feasible and could represent a significant advance in the brain-oriented care.
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Affiliation(s)
| | - Michal M Placek
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Marek Czosnyka
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Brenno Cabella
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Magdalena Kasprowicz
- 2 Department of Biomedical Engineering, Wroclaw University of Science and Technology, Wroclaw, Poland
| | - Topun Austin
- 1 The Rosie Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter Smielewski
- 3 Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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16
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Placek MM, Wachel P, Czosnyka M, Soehle M, Smielewski P, Kasprowicz M. Complexity of cerebral blood flow velocity and arterial blood pressure in subarachnoid hemorrhage using time-frequency analysis. Annu Int Conf IEEE Eng Med Biol Soc 2015; 2015:7700-7703. [PMID: 26738076 DOI: 10.1109/embc.2015.7320176] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [What about the content of this article? (0)] [Abstract] [MESH Headings] [Grants] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 06/05/2023]
Abstract
We investigated changes of time-frequency (TF) complexity, in terms of Rényi entropy and a measure of concentration, of middle cerebral blood flow velocity (CBFV) and arterial blood pressure in relation to the development of cerebral vasospasm in 15 patients after aneurysmal subarachnoid hemorrhage. Interhemispheric differences in the period of no vasospasm and vasospasm were also compared. Results show reduced complexity of TF representations of CBFV on the side of aneurysm before vasospasm was identified. This potentially can serve as an early-warning indicator of future derangement of cerebral circulation.
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