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Peter J. Kirkpatrick, Piotr Smielewski, Marek Czosnyka, David K. Menon and John D. Pickard

✓ A multimodality recording system was used in 14 ventilated patients with closed head injury to assess the potential use of near-infrared spectroscopy (NIRS) in the neurointensive care unit. Signals of intracranial pressure, cerebral perfusion pressure, peripheral oxygen saturation, jugular venous saturation, and NIRS-derived changes in the chromophores of oxy- and deoxyhemoglobin were digitized and recorded. After a review of 886 hours of continuous monitoring, 376 hours were considered free from artifact and were entered for final analysis. In nine of the patients 38 events were recorded that demonstrated clear changes in cerebral perfusion pressure accompanied by hemodynamic changes in middle cerebral artery flow velocity (transcranial Doppler) and cortical perfusion (laser Doppler flowmetry). Near-infrared spectroscopy showed correlated changes in 37 events (97%) whereas jugular venous saturation monitoring registered only 20 (53%). There was associated peripheral oxygen desaturation in eight cases (21%), intracranial hypertension in 10 (26%), and cerebral hyperemia in eight (21%). The remaining 12 events (32%) appeared to be complex changes of uncertain origin. Iatrogenic factors were identified as causative in 14 cases (37%). The potential application of NIRS in adults and the importance of using multiple parameter recording systems in the interpretation of cerebral events are discussed.

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Peter J. Kirkpatrick, Pietr Smielewski, Peter C. Whitfield, Marik Czosnyka, David Menon and John D. Pickard

✓ Near-infrared spectroscopy was used to monitor changes in the cerebral oxygenation state in 13 patients during carotid endarterectomy. Variations in the levels of the chromophores (oxygenated hemoglobin (HbO2), deoxygenated hemoglobin (Hb), and oxidized cytochrome (CytO2)), and the total hemoglobin content (tHb) were compared with changes in middle cerebral artery flow velocity measured using transcranial Doppler ultrasonography. Of eight patients who showed a fall in flow velocity on application of the internal carotid artery cross-clamp, seven demonstrated a rapid and closely correlated fall in HbO2 signal, and an increase in Hb. Levels of CytO2 and tHb remained unchanged. During endarterectomy, recovery of the HbO2 and Hb levels toward preclamp baseline values occurred in three of these patients. Intraoperative shunts accelerated recovery of HbO2 and Hb signals in two of three individuals. Release of the internal carotid cross-clamp resulted in a rapid increase in HbO2 and decrease in Hb signal in those patients in whom spontaneous recovery had not occurred; in five instances, a hyperemia evolved with raised flow velocity and HbO2 to above baseline values. Cross-clamping and subsequent reperfusion of the external carotid artery had no effect on any parameter measured. The authors conclude that near-infrared spectroscopy can register changes in cerebral oxygenation during carotid endarterectomy without significant contamination from extracranial tissues.

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Emma J. Williams, Cliff S. Bunch, T. Adrian Carpenter, Stephen P. M. J. Downey, Iona V. Kendall, Marek Czosnyka, John D. Pickard, John Martin and David K. Menon

✓ There is increasing recognition that magnetic resonance (MR) imaging and spectroscopy may provide important information in the assessment of patients with acute brain injury. However, optimum care of the acutely head injured patient requires monitoring of intracranial pressure (ICP). Although many monitoring modalities have been integrated into commercially available MR-compatible systems, there have been no reports of commonly used intraparenchymal ICP sensors in an MR environment. The authors describe the use of an ICP micromanometer probe in an MR environment, with a fiberoptic connection that interfaces the probe with a commercially available MR-compatible monitoring system. Phantom studies were performed to demonstrate the safety and compatibility of the modified MR system at 0.5 tesla. The safety of the device was assessed in relation to its interaction with the static, gradient, and radiofrequency fields used in MR imaging. The MR compatibility was documented by demonstrating that its performance was unaffected by the operation of imaging sequences and by showing that there was no degradation of the diagnostic quality of imaging data obtained during ICP monitoring.

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Christos Lazaridis, Stacia M. DeSantis, Peter Smielewski, David K. Menon, Peter Hutchinson, John D. Pickard and Marek Czosnyka

Object

Based on continuous monitoring of the pressure reactivity index (PRx), the authors defined individualized intracranial pressure (ICP) thresholds by graphing the relationship between ICP and PRx. These investigators hypothesized that an “ICP dose” based on individually assessed ICP thresholds would correlate more closely with the 6-month outcome when compared with ICP doses derived by the recommended universal thresholds of 20 and 25 mm Hg.

Methods

This study was a retrospective analysis of prospectively collected data from 327 patients with severe traumatic brain injury.

Results

Individualized thresholds were visually identified from graphs of PRx versus ICP; PRx > 0.2 was the cutoff. Intracranial pressure doses were then computed as the cumulative area under the curve above the defined thresholds in graphing ICP versus time. The term “Dose 20” (D20) was used to refer to an ICP threshold of 20 mm Hg; the markers D25 and DPRx were calculated similarly. Separate logistic regression models were fit with death as the outcome and each dose as the predictor, both alone and adjusted for covariates. The discriminative ability of each dose for mortality was assessed by receiver operating characteristic AUC analysis in which 5-fold cross-validation was used. A clearly identifiable PRx-based threshold was possible in 224 patients (68%). The DPRx (AUC 0.81, 95% CI 0.74–0.87) was found to have the highest area under the curve (AUC) over both D20 (0.75, 95% CI 0.68–0.81) and D25 (0.77, 95% CI 0.70–0.83); in the cross-validation model, DPRx remained the best discriminator of mortality (DPRx: AUC 0.77 [95% CI 0.68–0.89]; D20: 0.72 [95% CI 0.66–0.81]; and D25: 0.65 [95% CI 0.56–0.73]).

Conclusions

The authors explored the importance of different ICP thresholds for outcome by calculating patient-specific ICP doses based on the continuous monitoring of cerebrovascular pressure reactivity. They found that these individualized doses of intracranial hypertension were stronger predictors of death than doses derived from the universal thresholds of 20 and 25 mm Hg. The PRx could offer a method that can be directed toward individualizing the ICP threshold.

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Chiara Robba, Joseph Donnelly, Danilo Cardim, Tamara Tajsic, Manuel Cabeleira, Giuseppe Citerio, Paolo Pelosi, Peter Smielewski, Peter Hutchinson, David K. Menon and Marek Czosnyka

OBJECTIVE

Intracranial hypertension and impaired cerebral autoregulation are common causes of secondary injuries in patients with traumatic brain injury (TBI). The primary outcome of this study was to assess whether a noninvasive method to estimate intracranial pressure (ICP) based on the ultrasonography of the optic nerve sheath diameter (ONSD) measured at the time of neurocritical care unit (NCCU) admission is correlated with the mean ICP during NCCU stay. Secondary outcomes were to assess whether ONSD is correlated with the dose of ICP > 20 mm Hg and impaired autoregulation during NCCU stay and with instantaneous ICP and whether ONSD is associated with NCCU mortality.

METHODS

This prospective observational monocentric study included adults with severe TBI. ONSD was measured at NCCU admission, immediately after invasive ICP insertion. ONSD-predicted noninvasive ICP (nICPONSD) was calculated according the formula: nICPONSD = 5 × ONSD − 14 (nICPONSD in mm Hg, ONSD in mm). Autoregulation was measured using the pressure reactivity index (PRx).

RESULTS

In total, 100 patients were included in this study. ONSD was significantly correlated with mean ICP (r = 0.46, p < 0.0001), with mean PRx (r = 0.21, p = 0.04), and with the dose of ICP > 20 mm Hg during NCCU stay (r = 0.49, p < 0.0001). Admission nICPONSD was shown to be significantly correlated with instantaneous ICP (r = 0.85, p < 0.001). ONSD at admission was significantly correlated with NCCU mortality (p = 0.02).

CONCLUSIONS

ONSD measured at NCCU admission can give important information about patients at risk of developing intracranial hypertension and impaired autoregulation. ONSD examination could be useful to screen patients at admission to determine who would benefit from further invasive ICP monitoring.

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Virginia F. J. Newcombe, Robert C. Hawkes, Sally G. Harding, Roslyn Willcox, Sarah Brock, Peter J. Hutchinson, David K. Menon, T. Adrian Carpenter and Jonathan P. Coles

Magnetic resonance imaging and spectroscopy may provide important clinical information in the acute stages of brain injury. For this to occur it must be ensured that intracranial pressure (ICP) monitoring devices are safe to bring into the MR imaging suite. The authors tested a Codman MicroSensor ICP Transducer (Codman & Shurtleff, Inc.) within a 3-T MR imaging system using the transmit body coil and receive-only coils and the transmit-and-receive head coil. Extreme and rapid heating of 64°C was noted with the transducer wire in certain positions when using the transmit body coil and receive-only head coil. This is consistent with the phenomenon of resonance, and the probe was shown to have a distinct resonant response when coupled to HP 4195A Network Analyzer (Hewlett Packard). Coiling some of the transducer wire outside of the receive-only head coil reduced the generated current and so stopped the thermogenesis. This may be due to the introduction of a radiofrequency choke. The ICP transducer performed within clinically acceptable limits in both the static magnetic field and during imaging with high radiofrequency power when the excess wire was in this configuration. No heating was observed when a transmit-and-receive head coil was used. This study has shown when using a high-field magnet, the Codman ICP probe is MR conditional. That is, in the authors' system, it can be safely used with the transmit-and-receive head coil, but when using the transmit body coil the transducer wire must be coiled into concentric loops outside of the receive-only head coil.

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Angelos G. Kolias, Peter J. Hutchinson, David K. Menon, Geoffrey T. Manley, Clare N. Gallagher and Franco Servadei

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Arun K. Gupta, Peter J. Hutchinson, Tim Fryer, Pippa G. Al-Rawi, Dot A. Parry, Pawan S. Minhas, Rupert Kett-White, Peter J. Kirkpatrick, Julian C. Mathews, Steve Downey, Franklin Aigbirhio, John Clark, John D. Pickard and David K. Menon

Object. The benefits of measuring cerebral oxygenation in patients with brain injury are well accepted; however, jugular bulb oximetry, which is currently the most popular monitoring technique used has several shortcomings. The goal of this study was to validate the use of a new multiparameter sensor that measures brain tissue oxygenation and metabolism (Neurotrend) by comparing it with positron emission tomography (PET) scanning.

Methods. A Neurotrend sensor was inserted into the frontal region of the brain in 19 patients admitted to the neurointensive care unit. After a period of stabilization, the patients were transferred to the PET scanner suite where C15O, 15O2, and H2 15O PET scans were obtained to facilitate calculation of regional cerebral blood volume, O2 metabolism, blood flow, and O2 extraction fraction (OEF). Patients were given hyperventilation therapy to decrease arterial CO2 by approximately 1 kPa (7.5 mm Hg) and the same sequence of PET scans was repeated. For each scanning sequence, end-capillary O2 tension (PvO2) was calculated from the OEF and compared with the reading of brain tissue O2 pressure (PbO2) provided by the sensor.

In three patients the sensor was inserted into areas of contusion and these patients were eliminated from the analysis. In the subset of 16 patients in whom the sensor was placed in healthy brain, no correlation was found between the absolute values of PbO2 and PvO2 (r = 0.2, p = 0.29); however a significant correlation was obtained between the change in PbO2 (ΔPbO2) and the change in PvO2 (ΔPvO2) produced by hyperventilation in a 20-mm region of interest around the sensor (ρ = 0.78, p = 0.0035).

Conclusions. The lack of correlation between the absolute values of PbO2 and PvO2 indicates that PbO2 cannot be used as a substitute for PvO2. Nevertheless, the positive correlation between ΔPbO2 and ΔPvO2 when the sensor had been inserted into healthy brain suggests that tissue PO2 monitoring may provide a useful tool to assess the effect of therapeutic interventions in brain injury.

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Oral Presentations

2010 AANS Annual Meeting Philadelphia, Pennsylvania May 1–5, 2010