Cerebral blood flow augmentation using a cardiac-gated intracranial pulsating balloon pump in a swine model of elevated ICP

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OBJECTIVE

Augmenting brain perfusion or reducing intracranial pressure (ICP) dose is the end target of many therapies in the neuro-critical care unit. Many present therapies rely on aggressive systemic interventions that may lead to untoward effects. Previous studies have used a cardiac-gated intracranial balloon pump (ICBP) to model hydrocephalus or to flatten the ICP waveform. The authors sought to sought to optimize ICBP activation parameters to improve cerebral physiological parameters in a swine model of raised ICP.

METHODS

The authors developed a cardiac-gated ICBP in which the volume, timing, and duty cycle (time relative to a single cardiac cycle) of balloon inflation could be altered. They studied the ICBP in a swine model of elevated ICP attained by continuous intracranial fluid infusion with continuous monitoring of systemic and cerebral physiological parameters, and defined two specific protocols of ICBP activation.

RESULTS

Eleven swine were studied, 3 of which were studied to define the optimal timing, volume, and duty cycle of balloon inflation. Eight swine were studied with two defined protocols at baseline and with ICP gradually raised to a mean of 30.5 mm Hg. ICBP activation caused a consistent modification of the ICP waveform. Two ICBP activation protocols were used. Balloon activation protocol A led to a consistent elevation in cerebral blood flow (8%–25% above baseline, p < 0.00001). Protocol B resulted in a modest reduction of ICP over time (8%–11%, p < 0.0001) at all ICP levels. Neither protocol significantly affected systemic physiological parameters.

CONCLUSIONS

The preliminary results indicate that optimized protocols of ICBP activation may have beneficial effects on cerebral physiological parameters, with minimal effect on systemic parameters. Further studies are warranted to explore whether ICBP protocols may be of clinical benefit in patients with brain injuries with increased ICP.

ABBREVIATIONS ABP = arterial blood pressure; CBF = cerebral blood flow; ICBP = intracranial balloon pump; ICP = intracranial pressure.

Article Information

Correspondence Omer Doron: Hadassah-Hebrew University Medical Center, Jerusalem, Israel. omerdoronmd@gmail.com.

INCLUDE WHEN CITING Published online April 12, 2019; DOI: 10.3171/2019.1.JNS182864.

Disclosures Dr. Doron and Professor Barnea are listed as inventors on a patent of the device presented in this work.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    The ICBP system. Left section: Data acquisition unit, made of a digital control card that receives physiological analog signals from the sensors implanted in the animal model. Middle section: Computer acting as a control unit activating the pump. Right section: Computer-controlled syringe pump connected to a balloon catheter.

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    Animal procedure. A: Skin incisions: skull exposure and probe instrumentation (clockwise from top right—balloon catheter, ICP probe, CBF probe, and intraventricular infusion cannula). B: Partially deflated balloon, preinsertion. C: Swine positioning after carotid instrumentation and connection of balloon catheter to the pump. Figure is available in color online only.

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    ECG, ABP, ICP, balloon activation graph showing balloon volume (Bal. Vol.), and CBF are shown. With device activation, immediate change is noted in the ICP waveform with later changes in CBF. Figure is available in color online only.

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    Upper: Characteristic waveforms for protocol A and B. Lower: Characteristic ICP waveform change as balloon duty cycle (BDC) increased gradually from 10% to 30%. Figure is available in color online only.

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    Data overview, a single activation trial, protocol A type, at an ICP level of 18 mm Hg. ECG, ABP, ICP, balloon activation graph showing balloon volume (Bal. Vol.), and CBF are shown over a 12-minute period. With device activation, an immediate ICP waveform change is visible, without significant changes in heart rate or ABP. CBF increases with return to baseline some minutes after activation termination. ICP is transformed immediately with device activation and returns to baseline immediately after device activation termination. Figure is available in color online only.

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    Protocol A concept. Upper: Balloon inflation late in diastole causing “squeezing” effect on the venous tree, pushing venous blood outside the cranium. Lower: Balloon deflation later prior to systolic upstroke, causing instantaneous reduction ICP and in resistance to arterial blood inflow, augmenting the incoming arterial pulsation. Figure is available in color online only.

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    Protocol B concept. The nonlinear cranial P-V curve is shown. Balloon inflation during diastolic low pressure will result in a small pressure increase, while balloon deflation at high systolic pressure will result in a large pressure decrease.

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