Detection of Cerebral Compromise With Multimodality Monitoring in Patients With Subarachnoid Hemorrhage

Chen, H Isaac; Stiefel, Michael F.; Oddo, Mauro; Milby, Andrew H.; Maloney-Wilensky, Eileen; Frangos, Suzanne; Levine, Joshua M.; Kofke, W. Andrew; LeRoux, Peter D.

doi:10.1227/neu.0b013e3182191451

Cited by 122 publications

(93 citation statements)

References 72 publications

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“…41,42 Brain Tissue Oximetry Partial pressure of brain tissue oxygen (PbtO 2 ) is a complex physiological variable that likely reflects the interaction among oxygen delivery, extraction, and tissue demands. Although the exact determinants of PbtO 2 are unknown, it is clear that compromised PbtO 2 (Ͻ20 mm Hg) is associated with pathophysiological processes, including decreased CBF, 43 low arterial oxygen saturation, 44 lung injury, 45 and anemia. 46 PbtO 2 is measured with an invasive probe that uses a Clark-type electrode.…”

Section: Jugular Bulb Oximetrymentioning

confidence: 99%

Multimodal Monitoring in Subarachnoid Hemorrhage

Sandsmark

Kumar

Park

et al. 2012

Stroke

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In severely injured patients, the immediate goal of resuscitation is restoration and maintenance of adequate tissue metabolism by ensuring sufficient delivery of fuel, typically oxygen and glucose, to meet cellular metabolic demands. In neurocritical care, traditional goals of resuscitation-intracranial pressure (ICP), cerebral perfusion pressure (CPP), and the clinical examination-have been extrapolated from those of general critical care. These variables are analogous to central venous pressure, mean arterial pressure, and urine output and are similarly crude. These distant surrogates for cerebral perfusion do not account for dynamic changes in cerebral autoregulation, tissue metabolic rate, cellular fuel use, and microcirculatory dysfunction, all of which impact tissue metabolic health. Although standard, it seems intuitively obvious that a uniform approach of maintaining ICP Ͻ20 mm Hg and CPP Ͼ60 mm Hg is overly simplistic. This approach does not address either significant baseline differences in patient physiology nor the complex, dynamic, and variable pathophysiological changes that ensue after severe brain injury. A more tailored therapeutic strategy that responds to multiple simultaneously measured and more relevant physiological variables is logically appealing. Until recently, however, the requisite individual patient physiology was inaccessible at the bedside.The emergence of technology that allows for continuous real-time bedside monitoring of cerebral physiology marks a new era in neurocritical care. These monitors facilitate assessment of therapeutic efficacy and may provide more relevant physiological end points for resuscitation. Combining these monitors in a multimodal approach allows for the practice of goal-directed cerebral resuscitation that emphasizes the individual patient's unique neurological and systemic physiology.

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Section: Jugular Bulb Oximetrymentioning

confidence: 99%

Multimodal Monitoring in Subarachnoid Hemorrhage

Sandsmark

Kumar

Park

et al. 2012

Stroke

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“…They suggest that: "…several complementary monitors may be needed to optimize the care of poor-grade SAH patients", i.e. cerebral microdialysis and pbtO2 [304]. Similar reports have been presented for TBI patients [305].…”

Section: Cpp Managementmentioning

confidence: 65%

“…A combination of sedation and CPP augmentation were effective in 73 and 66% of episodes of compromised brain oxygen, respectively [303]. A report in poor grade SAH patients which adresses the relationship between CPP, ICP and pbtO2 confirms the observation that ICP and CPP monitoring "… may not always detect episodes of cerebral compromise in SAH patients" [304]. They suggest that: "…several complementary monitors may be needed to optimize the care of poor-grade SAH patients", i.e.…”

Section: Cpp Managementmentioning

confidence: 83%

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Systematic and Comprehensive Literature Review of Publications on Direct Cerebral Oxygenation Monitoring

Lang

Jaeger²

2013

TOCCMJ

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This review has been compiled to assess publications related to the clinical application of direct cerebral tissue oxygenation (pbtO2) monitoring published in international, peer-reviewed scientific journals, or major meeting reports published as journal supplements. Its goal was to extract relevant, i.e. positive and negative, information on indications, clinical application, safety issues and impact on clinical situations, as well as treatment strategies in neurosurgery, neurosurgical anaesthesiology, neurosurgical intensive care, neurology, and related specialties. For completeness' sake it also presents related basic science research and case reports. This review is an update of its previous edition published elsewhere in 2007. This review reflects publications from 2004 to 2012. Only relevant publications prior to 2004, which explicitly addressed or systematically examined the above issues, are included in this review and are listed in the reference section. Based on 349 citations it is the most comprehensive review available on direct cerebral oxygen monitoring to this date.Keywords: Review, cerebral oxygenation, raumedic, licox, neurotrend, cerebral partial pressure of oxygen, brain tissue oxygenation. METHODSThis review is based on a systematic "Medline" literature search using the following search terms: licox, neurotrend, neurovent, raumedic, brain tissue oxygen, brain tissue oxygenation, cerebral oxygenation, cerebral tissue oxygen, cerebral partial pressure of oxygen, btO2, ptiO2, pti(O)2, ptiO(2), pbrO2, PBr(O2), P(bt)O(2), P(br)O(2), PbrO(2), BTpO2, tP(O2), PbO2, PbtO2, Pbto, PbtO(2).Only few publications were not retrieved using this technique. They were, however, identified through personal communication with scientists in the field, meeting proceedings and reviewer assignments. This strategy provided sufficient certainty that relevant papers have not been missed. Unpublished meeting abstracts and published conference proceedings were excluded for this review expect for few which provided comparative studies between different probes. To address relevant matters, related to specific pbtO2 issues, selected non-peer reviewed papers published in supplements were also used only when no other peer-reviewed information was available. RESULTSThis review is based on a previous review [1]. It is currently based on 349 papers, 274 more papers compared to its previous version in 2007, which warrants the update.

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“…These biochemical signatures of metabolic distress both predict poor outcome. They can occur both in response to decreases in cerebral perfusion 9,24,26,52,54,60,61 and when CBF is normal. 56,64,70 "Nonischemic" metabolic crises are probably due to injury-associated mitochondrial dysfunction, which reduces the brain's ability to use oxygen and triggers compensatory hyperglycolysis.…”

Section: Cerebral Biochemistrymentioning

confidence: 99%

Unraveling the complexities of invasive multimodality neuromonitoring

Sinha¹,

Hudgins²,

Schuster³

et al. 2017

Neurosurgical Focus

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Acute brain injuries are a major cause of death and disability worldwide. Survivors of life-threatening brain injury often face a lifetime of dependent care, and novel approaches that improve outcome are sorely needed. A delayed cascade of brain damage, termed secondary injury, occurs hours to days and even weeks after the initial insult. This delayed phase of injury provides a crucial window for therapeutic interventions that could limit brain damage and improve outcome.A major barrier in the ability to prevent and treat secondary injury is that physicians are often unable to target therapies to patients’ unique cerebral physiological disruptions. Invasive neuromonitoring with multiple complementary physiological monitors can provide useful information to enable this tailored, precision approach to care. However, integrating the multiple streams of time-varying data is challenging and often not possible during routine bedside assessment.The authors review and discuss the principles and evidence underlying several widely used invasive neuromonitors. They also provide a framework for integrating data for clinical decision making and discuss future developments in informatics that may allow new treatment paradigms to be developed.

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Detection of Cerebral Compromise With Multimodality Monitoring in Patients With Subarachnoid Hemorrhage

Abstract: Our data demonstrate that ICP and CPP monitoring may not always detect episodes of cerebral compromise in SAH patients. Our data suggest that several complementary monitors may be needed to optimize the care of poor-grade SAH patients.

Cited by 122 publications

References 72 publications

Multimodal Monitoring in Subarachnoid Hemorrhage

Multimodal Monitoring in Subarachnoid Hemorrhage

Systematic and Comprehensive Literature Review of Publications on Direct Cerebral Oxygenation Monitoring

Unraveling the complexities of invasive multimodality neuromonitoring

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