Obesity and its implications on cerebral circulation and intracranial compliance in severe COVID‐19

Brasil, Sérgio; Renck, Alessandra Covallero; Taccone, Fabio Silvio; Solla, Davi Jorge Fontoura; Tomazini, Bruno Martins; Wayhs, Sâmia Yasin; Fonseca, Sérgio César da; Bassi, Estêvão; Lucena, Bruno; Nogueira, Ricardo de Carvalho; Paiva, Wellingson Silva; Teixeira, Manoel Jacobsen; Costa, Elaine Maria Frade; Malbouisson, Luíz Marcelo Sá

doi:10.1002/osp4.534

Cited by 15 publications

(17 citation statements)

References 53 publications

(60 reference statements)

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“…CVH and ICC impairment were identified using the different combinations of TCD and B4C values; in particular, P2/P1 ratio, mCBFV, eICP, PI, and eCPP were categorized and an arbitrary score was developed to describe different degrees of these alterations (Table 1), already applied in a previous published study [34]. For each variable, severity was defined by a CVH/ICC score from 1 to 4.…”

Section: Discussionmentioning

confidence: 99%

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Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill COVID-19 Patients: A Pilot Study

et al. 2021

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Introduction: One of the possible mechanisms by which the new coronavirus (SARS-Cov2) could induce brain damage is the impairment of cerebrovascular hemodynamics (CVH) and intracranial compliance (ICC) due to the elevation of intracranial pressure (ICP). The main objective of this study was to assess the presence of CVH and ICC alterations in patients with COVID-19 and evaluate their association with short-term clinical outcomes. Methods: Fifty consecutive critically ill COVID-19 patients were studied with transcranial Doppler (TCD) and non-invasive monitoring of ICC. Subjects were included upon ICU admission; CVH was evaluated using mean flow velocities in the middle cerebral arteries (mCBFV), pulsatility index (PI), and estimated cerebral perfusion pressure (eCPP), while ICC was assessed by using the P2/P1 ratio of the non-invasive ICP curve. A CVH/ICC score was computed using all these variables. The primary composite outcome was unsuccessful in weaning from respiratory support or death on day 7 (defined as UO). Results: At the first assessment (n = 50), only the P2/P1 ratio (median 1.20 [IQRs 1.00–1.28] vs. 1.00 [0.88–1.16]; p = 0.03) and eICP (14 [11–25] vs. 11 [7–15] mmHg; p = 0.01) were significantly higher among patients with an unfavorable outcome (UO) than others. Patients with UO had a significantly higher CVH/ICC score (9 [8–12] vs. 6 [5–7]; p < 0.001) than those with a favorable outcome; the area under the receiver operating curve (AUROC) for CVH/ICC score to predict UO was 0.86 (95% CIs 0.75–0.97); a score > 8.5 had 63 (46–77)% sensitivity and 87 (62–97)% specificity to predict UO. For those patients undergoing a second assessment (n = 29), after a median of 11 (5–31) days, all measured variables were similar between the two time-points. No differences in the measured variables between ICU non-survivors (n = 30) and survivors were observed. Conclusions: ICC impairment and CVH disturbances are often present in COVID-19 severe illness and could accurately predict an early poor outcome.

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Section: Discussionmentioning

confidence: 99%

“…ICC is a concept that is rarely considered during critical illnesses, mostly because of the lack of techniques available to assess it [34]. ICP invasive monitoring in COVID-19 patients would have been unethical and difficult to implement.…”

Section: Discussionmentioning

confidence: 99%

Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill COVID-19 Patients: A Pilot Study

et al. 2021

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“…Likewise, Asgari et al [33], with another dedicated software program (MOCAIP, University of California at Los Angeles, Los Angeles, CA, USA), performed automated ICP peak analysis during cerebrovascular changes. However, the opportunity of a non-invasive bedside observation of ICC has been recently developed (B4C, São Carlos, Brazil) and was validated in children with hydrocephalus [34] and severe COVID-19 cases [35,36]. This system provides the ICPW in real time, with automated P2/P1 ratio calculation.…”

Section: Discussionmentioning

confidence: 99%

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

et al. 2021

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Background: Morphological alterations in intracranial pressure (ICP) pulse waveform (ICPW) secondary to intracranial hypertension (ICP >20 mmHg) and a reduction in intracranial compliance (ICC) are well known indicators of neurological severity. The exclusive exploration of modifications in ICPW after either the loss of skull integrity or surgical procedures for intracranial hypertension resolution is not a common approach studied. The present study aimed to assess the morphological alterations in ICPW among neurocritical care patients with skull defects and decompressive craniectomy (DC) by comparing the variations in ICPW features according to elevations in mean ICP values. Methods: Patients requiring ICP monitoring because of acute brain injury were included. A continuous record of 10 min-length for the beat-by-beat analysis of ICPW was performed, with ICP elevation produced by means of ultrasound-guided manual internal jugular vein compression at the end of the record. ICPW features (peak amplitude ratio (P2/P1), time interval to pulse peak (TTP) and pulse amplitude) were counterweighed between baseline and compression periods. Results were distributed for three groups: intact skull (exclusive burr hole for ICP monitoring), craniotomy/large fractures (group 2) or DC (group 3). Results: 57 patients were analyzed. A total of 21 (36%) presented no skull defects, 21 (36%) belonged to group 2, whereas 15 (26%) had DC. ICP was not significantly different between groups: ±15.11 for intact, 15.33 for group 2 and ±20.81 mmHg for group 3, with ICP-induced elevation also similar between groups (p = 0.56). Significant elevation was observed for the P2/P1 ratio for groups 1 and 2, whereas a reduction was observed in group 3 (elevation of ±0.09 for groups 1 and 2, but a reduction of 0.03 for group 3, p = 0.01), and no significant results were obtained for TTP and pulse amplitudes. Conclusion: In the present study, intracranial pressure pulse waveform analysis indicated that intracranial compliance was significantly more impaired among decompressive craniectomy patients, although ICPW indicated DC to be protective for further influences of ICP elevations over the brain. The analysis of ICPW seems to be an alternative to real-time ICC assessment.

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“…The first clinical study that applied this new technology successfully correlated the P2/P1 ratio with ICP in children with hydrocephalus [24], whereas another study assessed cerebrovascular disorders using transcranial Doppler and B4C devices in patients with severe COVID-19. In this study, a progressive score from 5 to 20 was created by combining the results of both techniques, indicating that the worse the cerebral hemodynamics and B4C P2/P1 ratio alterations, the higher the probability of either the impossibility of mechanical ventilation weaning or even death until seven days after examinations (P<0.00001) [37], with B4C P2/P1 ratio alteration observed more frequently among patients who are obese (P=0.029) [38].…”

Section: Main Findingsmentioning

confidence: 99%

A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care

Brasil¹,

Solla²,

Nogueira³

et al. 2021

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We validated a new noninvasive tool (B4C) to assess intracranial pressure waveform (ICPW) morphology in a set of neurocritical patients, correlating the data with ICPW obtained from invasive catheter monitoring. Materials and Methods: Patients undergoing invasive intracranial pressure (ICP) monitoring were consecutively evaluated using the B4C sensor. Ultrasound-guided manual internal jugular vein (IJV) compression was performed to elevate ICP from the baseline. ICP values, amplitudes, and time intervals (P2/P1 ratio and time-to-peak [TTP]) between the ICP and B4C waveform peaks were analyzed. Results: Among 41 patients, the main causes for ICP monitoring included traumatic brain injury, subarachnoid hemorrhage, and stroke. Bland-Altman’s plot indicated agreement between the ICPW parameters obtained using both techniques. The strongest Pearson’s correlation for P2/P1 and TTP was observed among patients with no cranial damage (r = 0.72 and 0.85, respectively) in detriment of those who have undergone craniotomies or craniectomies. P2/P1 values of 1 were equivalent between the two techniques (area under the receiver operator curve [AUROC], 0.9) whereas B4C cut-off 1.2 was predictive of intracranial hypertension (AUROC 0.9, p < 000.1 for ICP > 20 mmHg). Conclusion: B4C provided biometric amplitude ratios correlated with ICPW variation morphology and is useful for noninvasive critical care monitoring.

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Obesity and its implications on cerebral circulation and intracranial compliance in severe COVID‐19

Cited by 15 publications

References 53 publications

Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill COVID-19 Patients: A Pilot Study

Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill COVID-19 Patients: A Pilot Study

Intracranial Compliance Assessed by Intracranial Pressure Pulse Waveform

A Novel Noninvasive Technique for Intracranial Pressure Waveform Monitoring in Critical Care

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