Safety profile of an intracranial multimodal monitoring bolt system for neurocritical care: a single-center experience

Abstract

BackgroundIntracranial multimodality monitoring (iMMM) is increasingly used in acute brain injured patients; however, safety and reliability remain major concerns to its routine implementation. MethodsWe performed a retrospective study including all patients undergoing iMMM at a single European center between July 2016 and January 2020. Brain tissue oxygenation probe (PbtO 2 ), alone or in combination with a microdialysis catheter and/or an 8-contact depth EEG electrode, was inserted using a triple lumen bolt system and targeting normal-appearing at risk brain area on the injured side, whenever possible. Surgical complications, adverse events and technical malfunctions, directly associated with iMMM were collected. A blinded imaging review was performed by an independent radiologist. Results113 patients with 123 iMMM insertions were included for a median monitoring time of 9 [3-14] days. Of those, 93 (76%) patients had only PbtO 2 probe insertion and 30 (24%) had also microdialysis and/or iEEG monitoring. SAH was the most frequent indication for iMMM (n = 60, 53%). At least one complication was observed in 67/123 (54%) iMMM placement, corresponding to 58/113 (51%) patients. Misplacement was observed in 16/123 (13%), resulting in a total of 6/16 (38%) malfunctioning PbtO 2 catheters. Intracranial hemorrhage was observed in 14 iMMM placements (11%), of which one required surgical drainage. Five placements were complicated by pneumocephalus and 4 with bone fragments, none of these requiring additional surgery. No CNS infection related to iMMM was observed. Seven (6%) probes were accidentally dislodged and 2 probes (2%) were accidentally broken. Ten PbtO 2 probes (8%) presented a technical malfunction after a median of 9 [ranges: 2-24] days after initiation of monitoring and 4 of them were replaced. ConclusionsIn this study, a high occurrence of complications related to iMMM was observed, although most of them did not require speci c interventions and did not result in malfunctioning monitoring.

Complications of Intracranial Multimodal Monitoring for Neurocritical Care: A Systematic Review and Meta-Analysis

“…In the most extensive series (501 patients), Bailey et al [8] reported only one infection due to an improper bolt placement technique with a faulty seal causing a CSF leak and potentially bacterial meningitis. Al Barajraji et al [16] reported that nine (8%) of their patients developed CNS infections. However, despite a relatively high mean monitoring time, they did not attribute it to iMMM; no intraventricular misplacement was associated with CNS infections [16].…”

“…Forty-one iMMM dislodgements with rates of 5.7% and 7.8% and six breakings with rates of 1.62% and 3.88% were retrieved from series by Al Barajraji et al [16] and Dings et al [17]. Stuart et al [14] and Foreman et al [7] reported that inadvertent monitoring discontinuation occurred for 43% and 58% of their patients, respectively.…”

“…Furthermore, surgical procedure details (e.g., type of cranial drill used, craniotomy diameter), iMMM technical features (e.g., bolt specifications, number and concentration of inserted probes in close vicinity imposed by multi-lumen devices, implantation depth), or repeated insertions were not consistently reported or investigated. Only Al Barajraji et al [16] performed risk factor analyses, investigating the underlying ABI etiology (e.g., TBI and potential diffuse axonal injury) and the number of probes inserted through the three-lumen bolt as determinants for PIH without finding significant associations. As stated, most iMMM reported in the literature used a three-lumen bolt device requiring a relatively large burr hole to insert up to three probes.…”

Combined depth and scalp electroencephalographic monitoring in acute brain injury: Yield and prognostic value

“…An eight-contact dEEG electrode (Dixi Medical, Besançon, France) was placed via a bolt system in patients with ABI by a neurosurgeon in the operating room. A detailed description of the surgical procedure of dEEG was published in our previous article [10]. Briefly, the dEEG electrode was positioned 1.5 cm anteriorly from Kocher's point, targeting the frontal lobe of the injured side or in the case of surgical constraints (i.e., large craniectomy, large intracranial hematoma, hydrocephalus) in the contralateral side.…”

“…In a previous study, we demonstrated that the implementation of an eight‐contact dEEG electrode inserted using a triple‐lumen bolt system was safe [10]. In this study, we aimed to explore the concordance between electrophysiological activities displayed on dEEG and those on scEEG in patients with ABI.…”