Brain tissue oxygenation guided therapy and outcome in non-traumatic subarachnoid hemorrhage

Bogossian, Elisa Gouvêa; Diaferia, Daniela; Djangang, Narcisse Ndieugnou; Menozzi, Marco; Vincent, Jean‐Louis; Talamonti, Marta; Dewitte, O.; Peluso, Lorenzo; Barrit, Sami; Barajraji, Mejdeddine Al; André, Joachim; Schuind, Sophie; Créteur, Jacques; Taccone, Fabio Silvio

doi:10.1038/s41598-021-95602-6

Cited by 30 publications

(26 citation statements)

References 50 publications

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“…Unklar ist allerdings, ob therapeutische Maßnahmen, die sich aus dem PbtO 2 -Monitoring ableiten, zu einer Verbesserung des klinischen Outcomes führen. In einer monozentrischen retrospektiven Studie wurden Maßnahmen, Komplikationen und Outcome verglichen zwischen einer ICP-gesteuerten Therapie ( n = 48) und einer ICP/PbtO 2 -gesteuerten Therapie ( n = 54; [ 9 ]). Ein Großteil (87 %) der Patienten mit PbtO 2 -Sonde wiesen mindestens eine detektierte hypoxische Phase auf.…”

Section: Neues Zum Monitoring Der Aneurysmatischen Subarachnoidalblutungunclassified

Das ist neu in der Neurointensiv- und Notfallmedizin: die wichtigsten Studien des Jahres im Rück- und Überblick

2022

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Die vorliegende Übersichtsarbeit fasst wichtige klinische Studien der neurologischen Notfall- und Intensivmedizin zwischen 2020 und 2021 zusammen zu den Themen: rekanalisierende Therapie beim ischämischen Schlaganfall, Anwendbarkeit und Auswirkung eines zerebralen Sauerstoffgewebemonitorings bei Subarachnoidalblutung, Wirksamkeit induzierter Hypothermie bei Patienten mit „cardiac arrest“ (CA), Wertigkeit früher kranialer Bildgebung nach CA, Relevanz eines schnellen Managements und medikamentöser Therapie beim Status epilepticus sowie Inzidenz von Critical-illness-Polyneuropathie-Myopathie bei intensivpflichtigen COVID-Patienten.

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Section: Neues Zum Monitoring Der Aneurysmatischen Subarachnoidalblutungunclassified

Das ist neu in der Neurointensiv- und Notfallmedizin: die wichtigsten Studien des Jahres im Rück- und Überblick

2022

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“…For example, Hosmann et al (2022) define indications for cerebral ischemia as CMD L/P-ratio >40 CMD-glycerol >100 μmol/L, CMD-lactate >4 mmol/L, whereas Nyholm et al (2017) defined cerebral ischemia as CMD-L/P ratio >40 and CMD-pyruvate <50 mol/L). For brain tissue hypoxia monitored by PbtO 2 there were in general two definitions used: PbtO 2 <15 mmHg ( Burnol et al, 2021 ; Hosmann et al, 2021 ) or <20 mmHg ( Le Roux et al, 2014 ; Gagnon et al, 2020 ; Sekhon et al, 2020 ; Gouvea Bogossian et al, 2021 ).…”

Section: Results Objective Ii: Secondary Injuriesmentioning

confidence: 99%

“…of studies References ABP-management Arterial blood pressure-management 4 (Jakkula et al, 2018;Calviello et al, 2019;Sekhon et al, 2019;Kovacs et al, 2021) b Biomarkers Neuroglobin, prostacyclin, succinate 3 (Ding et al, 2019;Koskinen et al, 2019;Khellaf et al, 2022) a Fluid management CSF drainage, hypertonic saline, and/or fluid management 5 (Akbik et al, 2017;Carteron et al, 2018;Hoiland et al, 2021;Rass et al, 2021;Bernini et al, 2022) Mixed interventions Nimodipine, ICP/CPP management (vasopressors, sedation, etc. ), hyperoxia, glucose, head elevation/flat position 11 (Bele et al, 2015;Lin et al, 2015;Okonkwo et al, 2017;Sekhon et al, 2017;Rass et al, 2019;Veldeman et al, 2020a;Veldeman et al, 2020b;Fergusson et al, 2021;Gouvea Bogossian et al, 2021;Khellaf et al, 2022;Winberg et al, 2022) a…”

Section: Intervention Group Interventionsmentioning

confidence: 99%

Cerebral multimodality monitoring in adult neurocritical care patients with acute brain injury: A narrative review

et al. 2022

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Cerebral multimodality monitoring (MMM) is, even with a general lack of Class I evidence, increasingly recognized as a tool to support clinical decision-making in the neuroscience intensive care unit (NICU). However, literature and guidelines have focused on unimodal signals in a specific form of acute brain injury. Integrating unimodal signals in multiple signal monitoring is the next step for clinical studies and patient care. As such, we aimed to investigate the recent application of MMM in studies of adult patients with traumatic brain injury (TBI), subarachnoid hemorrhage (SAH), intracerebral hemorrhage (ICH), acute ischemic stroke (AIS), and hypoxic ischemic brain injury following cardiac arrest (HIBI). We identified continuous or daily updated monitoring modalities and summarized the monitoring setting, study setting, and clinical characteristics. In addition, we discussed clinical outcome in intervention studies. We identified 112 MMM studies, including 11 modalities, over the last 7 years (2015–2022). Fifty-eight studies (52%) applied only two modalities. Most frequently combined were ICP monitoring (92 studies (82%)) together with PbtO2 (63 studies (56%). Most studies included patients with TBI (59 studies) or SAH (53 studies). The enrollment period of 34 studies (30%) took more than 5 years, whereas the median sample size was only 36 patients (q1- q3, 20–74). We classified studies as either observational (68 studies) or interventional (44 studies). The interventions were subclassified as systemic (24 studies), cerebral (10 studies), and interventions guided by MMM (11 studies). We identified 20 different systemic or cerebral interventions. Nine (9/11, 82%) of the MMM-guided studies included clinical outcome as an endpoint. In 78% (7/9) of these MMM-guided intervention studies, a significant improvement in outcome was demonstrated in favor of interventions guided by MMM. Clinical outcome may be improved with interventions guided by MMM. This strengthens the belief in this application, but further interdisciplinary collaborations are needed to overcome the heterogeneity, as illustrated in the present review. Future research should focus on increasing sample sizes, improved data collection, refining definitions of secondary injuries, and standardized interventions. Only then can we proceed with complex outcome studies with MMM-guided treatment.

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“…The value of adjusting hemodynamic and ventilator parameters based on brain tissue oxygen (PbtO 2 ) is being investigated. Observational studies in TBI and SAH have shown higher mortality in association with decreased PbtO 2 levels and suggested outcome benefits with PbtO 2 -directed therapy [53][54][55][56][57][58]. The Brain Oxygen Optimization in Severe TBI (BOOST-3) trial, a phase 3 RCT, is assessing the potential to improve neurological outcomes in TBI by comparing ICU care guided by ICP monitoring only against an ICP plus PbtO 2 -guided management strategy [59].…”

Section: Mechanical Ventilation Targets In Sabimentioning

confidence: 99%

Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome

Matin

Sarhadi

Crooks

et al. 2022

Curr Treat Options Neurol

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Purpose of Review To summarize pathophysiology, key conflicts, and therapeutic approaches in managing concomitant severe acute brain injury (SABI) and acute respiratory distress syndrome (ARDS). Recent Findings ARDS is common in SABI and independently associated with worse outcomes in all SABI subtypes. Most landmark ARDS trials excluded patients with SABI, and evidence to guide decisions is limited in this population. Potential areas of conflict in the management of patients with both SABI and ARDS are (1) risk of intracranial pressure (ICP) elevation with high levels of positive end-expiratory pressure (PEEP), permissive hypercapnia due to lung protective ventilation (LPV), or prone ventilation; (2) balancing a conservative fluid management strategy with ensuring adequate cerebral perfusion, particularly in patients with symptomatic vasospasm or impaired cerebrovascular blood flow; and (3) uncertainty about the benefit and harm of corticosteroids in this population, with a mortality benefit in ARDS, increased mortality shown in TBI, and conflicting data in other SABI subtypes. Also, the widely adapted partial pressure of oxygen (P a O 2 ) target of > 55 mmHg for ARDS may exacerbate secondary brain injury, and recent guidelines recommend higher goals of 80–120 mmHg in SABI. Distinct pathophysiology and trajectories among different SABI subtypes need to be considered. Summary The management of SABI with ARDS is highly complex, and conventional ARDS management strategies may result in increased ICP and decreased cerebral perfusion. A crucial aspect of concurrent management is to recognize the risk of secondary brain injury in the individual patient, monitor with vigilance, and adjust management during critical time windows. The care of these patients requires meticulous attention to oxygenation and ventilation, hemodynamics, temperature management, and the neurological exam. LPV and prone ventilation should be utilized, and supplemented with invasive ICP monitoring if there is concern for cerebral edema and increased ICP. PEEP titration should be deliberate, involving measures of hemodynamic, pulmonary, and brain physiology. Serial volume status assessments should be performed in SABI and ARDS, and fluid management should be individualized based on measures of brain perfusion, the neurological exam, and cardiopulmonary status. More research is needed to define risks and benefits in corticosteroids in this population.

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Brain tissue oxygenation guided therapy and outcome in non-traumatic subarachnoid hemorrhage

Cited by 30 publications

References 50 publications

Das ist neu in der Neurointensiv- und Notfallmedizin: die wichtigsten Studien des Jahres im Rück- und Überblick

Das ist neu in der Neurointensiv- und Notfallmedizin: die wichtigsten Studien des Jahres im Rück- und Überblick

Cerebral multimodality monitoring in adult neurocritical care patients with acute brain injury: A narrative review

Brain-Lung Crosstalk: Management of Concomitant Severe Acute Brain Injury and Acute Respiratory Distress Syndrome

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