Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners

Casault, Colin; Couillard, Philippe; Kromm, Julie; Rosenthal, Eric S.; Kramer, Andreas H.; Brindley, Peter G.

doi:10.1177/1751143720980273

Cited by 14 publications

(14 citation statements)

References 88 publications

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“…Despite traumatic brain injury (TBI) being a leading cause of death and disability worldwide [1], current guideline-based management, focused on intracranial pressure (ICP) and cerebral perfusion pressure (CPP), has resulted in limited recent improvements in outcome following moderate and severe TBI [2,3]. Interest has shifted towards personalized medicine-based strategies that leverage contemporary multimodal monitoring techniques [4,5]. Two methods that have come to the forefront are brain tissue oxygen tension (PbtO 2 ) and ICP-based cerebrovascular pressure reactivity monitoring [6,7].…”

Section: Introductionmentioning

confidence: 99%

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Gomez

Sekhon

Griesdale

et al. 2022

ICMx

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Background Brain tissue oxygen tension (PbtO2) and cerebrovascular pressure reactivity monitoring have emerged as potential modalities to individualize care in moderate and severe traumatic brain injury (TBI). The relationship between these modalities has had limited exploration. The aim of this study was to examine the relationship between PbtO2 and cerebral perfusion pressure (CPP) and how this relationship is modified by the state of cerebrovascular pressure reactivity. Methods A retrospective multi-institution cohort study utilizing prospectively collected high-resolution physiologic data from the CAnadian High Resolution-TBI (CAHR-TBI) Research Collaborative database collected between 2011 and 2021 was performed. Included in the study were critically ill TBI patients with intracranial pressure (ICP), arterial blood pressure (ABP), and PbtO2 monitoring treated in any one of three CAHR-TBI affiliated adult intensive care units (ICU). The outcome of interest was how PbtO2 and CPP are related over a cohort of TBI patients and how this relationship is modified by the state of cerebrovascular reactivity, as determined using the pressure reactivity index (PRx). Results A total of 77 patients met the study inclusion criteria with a total of 377,744 min of physiologic data available for the analysis. PbtO2 produced a triphasic curve when plotted against CPP like previous population-based plots of cerebral blood flow (CBF) versus CPP. The triphasic curve included a plateau region flanked by regions of relative ischemia (hypoxia) and hyperemia (hyperoxia). The plateau region shortened when cerebrovascular pressure reactivity was disrupted compared to when it was intact. Conclusions In this exploratory analysis of a multi-institution high-resolution physiology TBI database, PbtO2 seems to have a triphasic relationship with CPP, over the entire cohort. The CPP range over which the plateau exists is modified by the state of cerebrovascular reactivity. This indicates that in critically ill TBI patients admitted to ICU, PbtO2 may be reflective of CBF.

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Section: Introductionmentioning

confidence: 99%

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Gomez

Sekhon

Griesdale

et al. 2022

ICMx

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“…TBI treatment based on MMM-derived optimal cerebral perfusion has demonstrated improved clinical outcomes, especially in older patients who may have reduced autoregulatory capacity [81]. PRx allows for real-time measurement of cerebrovascular autoregulation [82] and may help to predict the need for surgical intervention in severe TBI [83][84][85]. Measurement of brain oxygenation parameters such as PbtO2 allows for rapid implementation of theraputic interventions to correct cerebral hypoxia [82,86], and measurement of PbtO2 and ICP in the BOOST-II trial was suggested to improve secondary injury after TBI demonstrating the potential effect of such early interventions [87].…”

Section: Multimodal Neuromonitoringmentioning

confidence: 99%

“…PRx allows for real-time measurement of cerebrovascular autoregulation [82] and may help to predict the need for surgical intervention in severe TBI [83][84][85]. Measurement of brain oxygenation parameters such as PbtO2 allows for rapid implementation of theraputic interventions to correct cerebral hypoxia [82,86], and measurement of PbtO2 and ICP in the BOOST-II trial was suggested to improve secondary injury after TBI demonstrating the potential effect of such early interventions [87]. Measurement of PbtO2, CPP and arterial oxygen saturation has been used to guide treatment of cerebral hypoxia in severe TBI, helping to uncover physiologic states that may lead to impaired brain oxygen metabolism [88].…”

Section: Multimodal Neuromonitoringmentioning

confidence: 99%

Multi-mechanistic Approaches to the Treatment of Traumatic Brain Injury: A Review

Lynch¹,

Narayan²,

Li³

2023

Preprint

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Traumatic brain injury (TBI) is a leading cause of death and disability worldwide. Despite extensive research efforts, the majority of trialed monotherapies to date have failed to demonstrate significant benefit. It has been suggested that this is due to the complex pathophysiology of TBI, which may possibly be addressed by a combination of therapeutic interventions. In this article, we have reviewed combinations of different pharmacologic treatments, combinations of non-pharmacologic interventions, and combined pharmacologic and non-pharmacologic interventions for TBI. Both preclinical and clinical studies have been included. While promising results have been found in animal models, clinical trials of combination therapies have not yet shown clear benefit. This may possibly be due to their application without consideration of the evolving pathophysiology of TBI. Improvements of this paradigm may come from novel interventions guided by multimodal neuromonitoring and multimodal imaging techniques, as well as the application of multi-targeted non-pharmacologic and endogenous therapies. There also needs to be a greater representation of female subjects in preclinical and clinical studies.

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“…It is recognized that a “normal” PbtO 2 can be greater than 15–20 mmHg and lower values may indicate cerebral hypoxia and are associated with a greater lactate/glucose ratio and increased glycerol levels. However, there is no universal consensus on the threshold at with tissue injury occurs ( Casault et al, 2020 ).…”

Section: Neuromonitoring To Personalize Tbi Therapymentioning

confidence: 99%

A Precision Medicine Agenda in Traumatic Brain Injury

2022

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Traumatic brain injury remains a leading cause of death and disability across the globe. Substantial uncertainty in outcome prediction continues to be the rule notwithstanding the existing prediction models. Additionally, despite very promising preclinical data, randomized clinical trials (RCTs) of neuroprotective strategies in moderate and severe TBI have failed to demonstrate significant treatment effects. Better predictive models are needed, as the existing validated ones are more useful in prognosticating poor outcome and do not include biomarkers, genomics, proteonomics, metabolomics, etc. Invasive neuromonitoring long believed to be a “game changer” in the care of TBI patients have shown mixed results, and the level of evidence to support its widespread use remains insufficient. This is due in part to the extremely heterogenous nature of the disease regarding its etiology, pathology and severity. Currently, the diagnosis of traumatic brain injury (TBI) in the acute setting is centered on neurological examination and neuroimaging tools such as CT scanning and MRI, and its treatment has been largely confronted using a “one-size-fits-all” approach, that has left us with many unanswered questions. Precision medicine is an innovative approach for TBI treatment that considers individual variability in genes, environment, and lifestyle and has expanded across the medical fields. In this article, we briefly explore the field of precision medicine in TBI including biomarkers for therapeutic decision-making, multimodal neuromonitoring, and genomics.

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Multimodal brain monitoring following traumatic brain injury: A primer for intensive care practitioners

Cited by 14 publications

References 88 publications

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study

Multi-mechanistic Approaches to the Treatment of Traumatic Brain Injury: A Review

A Precision Medicine Agenda in Traumatic Brain Injury

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