Rapid and selective cerebral hypothermia achieved using a cooling helmet

Restricted access

Object

Hypothermia is by far the most potent neuroprotectant. Nevertheless, timely and safe delivery of hypothermia remains a clinical challenge. To maximize neuroprotection yet minimize systemic complications, ultra-early delivery of selective cerebral hypothermia by Emergency Medical Service (EMS) personnel in the field would be advantageous. The authors (W.E. and H.W.) have developed a cooling helmet by using National Aeronautics and Space Administration spinoff technology. In this study its effectiveness in lowering brain temperature in patients with severe stroke or head injury is examined.

Methods

Patients were randomly assigned to groups receiving either the cooling helmet or no cooling, and brain temperatures (0.8 cm below the cortical surface) were continuously monitored for a mean of 48 to 72 hours with a Neurotrend sensor and then compared with the patients' core temperatures. There were eight patients in the study group and six in the control group. The mean change in temperature (brain — body temperature) calculated from 277 data hours in the study group was − 1.6°C compared with a mean change in temperature of + 0.22°C calculated from 309 data hours in the control group. This was statistically significant (p < 0.0001). On average, 1.84°C of brain temperature reduction (range 0.9–2.4°C) was observed within 1 hour of helmet application. It took a mean of 3.4 hours (range 2–6 hours) to achieve a brain temperature lower than 34°C and 6.67 hours (range 1–12 hours) before systemic hypothermia (< 36°C) occurred. Use of the helmet resulted in no significant complications. There was, however, one episode of asymptomatic bradycardia (heart rate < 40) that responded to a 0.5°C body temperature increase.

Conclusions

This helmet delivers initial rapid and selective brain cooling and maintains a significant temperature gradient between the core and brain temperatures throughout the hypothermic period to provide sufficient regional hypothermia yet minimize systemic complications. It results in delayed systemic hypothermia, creating a safe window for possible ultra-early delivery of regional hypothermia by EMS personnel in the field.

Article Information

Address reprint requests to: William C. Olivero, M.D., Department of Neurosurgery, University of Illinois College of Medicine at Peoria, P.O. Box 1649, Peoria, Illinois 61656. email: olib@uic.edu.

© AANS, except where prohibited by US copyright law.

Headings

Figures

  • View in gallery

    Photograph showing the helmet worn by William Elkins, a NASA scientist, who invented this technology. The cooling helmet has an outer pneumatic liner pressurized to allow close contact with the cranium and neck. The device also is adjustable to fit a significant range of head sizes.

  • View in gallery

    Graph showing that, within 15 minutes after application of the cooling helmet, the brain temperature dropped by approximately 2°C, whereas the core temperature did not drop below 37°C until 4 to 5 hours later. The cooling helmet maintained brain temperature at approximately 1.5 to 2.5°C below core temperature throughout the 48-hour cooling period. When the core temperature dropped to 32°C and brain temperature dropped to 29.4°C, active body warming was initiated to minimize the risk of cardiac arrhythmia. After the cooling helmet was removed at Hour 48, the brain temperature approached the core temperature within 1 to 2 hours, and then both rose gradually to 37°C over a 30-hour period. B-temp = brain temperature; C-temp = core temperature.

References

1.

Almond CHJones JCSnyder HMet al: Cooling gradients and brain damage with deep hypothermia. J Thorac Cardiovasc Surg 48:8908971964J Thorac Cardiovasc Surg 48:

2.

Barone FFeuerstein GZWhite RF: Brain cooling during transient focal ischemia provides complete neuroprotection. Neurosci Biobehav Rev 21:31441996Neurosci Biobehav Rev 21:

3.

Bernard SAGray TWBuist MDet al: Treatment of comatose survivors of out-of-hospital cardiac arrest with induced hypothermia. N Engl J Med 346:5575632002N Engl J Med 346:

4.

Busto RDietrich WDGlobus MYTet al: The importance of brain temperature in cerebral ischemic injury. Stroke 20:111311141989Stroke 20:

5.

Busto RGinsberg MD: The influence of altered brain temperature in cerebral ischemiaGinsberg MDBogousslavsky J (eds): Malden, MA: Blackwell Science1998287307

6.

Carroll MBeek O: Protection against hippocampal CA1 cell loss by post-ischemic hypothermia is dependent on delay of initiation and duration. Metab Brain Dis 7:45501992Metab Brain Dis 7:

7.

Chater NAAdams JELeake TBet al: Cardiovascular effects of local brain stem cooling. Surg Forum 11:4084101960Surg Forum 11:

8.

Clifton GLAllen SBerry Jet al: Systemic hypothermia in treatment of brain injury. J Neurotrauma 9 (Suppl 2):S487S4951992J Neurotrauma 9 (Suppl 2):

9.

Clifton GLMiller ERChoi SCet al: Lack of effect of induction of hypothermia after acute brain injury. N Engl J Med 344:5565632001N Engl J Med 344:

10.

Coimbra CWieloch T: Moderate hypothermia mitigates neuronal damage in the rat brain when initiated several hours following transient cerebral ischemia. Acta Neuropathol 87:3253311994Acta Neuropathol 87:

11.

Colbourne FCorbett D: Delayed and prolonged post-ischemic hypothermia is neuroprotective in the gerbil. Brain Res 654:2652721994Brain Res 654:

12.

Colbourne FCorbett D: Delayed postischemic hypothermia: a six month survival study using behavioral and histologic assessments of neuroprotection. J Neurosci 15:725072601995J Neurosci 15:

13.

Colbourne FLi HBuchan AM: Indefatigable CA1 sector neuroprotection with mild hypothermia induced 6 hours after severe forebrain ischemia in rats. J Cereb Blood Flow Metab 19:7427491999J Cereb Blood Flow Metab 19:

14.

Corbett DHamilton MColbourne F: Persistent neuroprotection with prolonged postischemic hypothermia in adult rats subjected to transient middle cerebral artery occlusion. Exp Neurol 163:2002062000Exp Neurol 163:

15.

Costal MOwens GWoldring S: Experimental production of cerebral hypothermia by ventricular perfusion techniques. J Neurosurg 20:1121171963J Neurosurg 20:

16.

Dietrich WDBusto RAlonso Oet al: Intraischemic but not postischemic brain hypothermia protects chronically following global forebrain ischemia in rats. J Cereb Blood Flow Metab 13:5415491993J Cereb Blood Flow Metab 13:

17.

Dietrich WDBusto RGlobus MYTet al: Brain damage and temperature: cellular and molecular mechanismsSiesjo BKWieloch T (eds): Cellular and Molecular Mechanisms of Ischemic Brain Damage. Philadelphia: Lippincott-Raven1996177197Cellular and Molecular Mechanisms of Ischemic Brain Damage.

18.

Du Boulay GHLawton MWallis A: The story of the internal carotid artery of mammals: from Galen to sudden infant death syndrome. Neuroradiology 40:6977031998Neuroradiology 40:

19.

Eisenburger PSafar P: Life supporting first aid training of the public—review and recommendations. Resuscitation 41:3181999Resuscitation 41:

20.

Frank SMFleisher LABreslow MJet al: Perioperative maintenance of normothermia reduces the incidence of morbid cardiac events. A randomized clinical trial. JAMA 277:112711341997JAMA 277:

21.

Garcia JH: The evolution of brain infarcts. A review. J Neuropathol Exp Neurol 51:3873931992Garcia JH: The evolution of brain infarcts. A review. J Neuropathol Exp Neurol 51:

22.

Garcia JHLiu KFHo KL: Neuronal necrosis after middle cerebral artery occlusion in Wistar rats progresses at different time intervals in the caudoputamen and the cortex. Stroke 26:6366431995Stroke 26:

23.

Gelman BSchleien CLLohe Aet al: Selective brain cooling in infant piglets after cardiac arrest and resuscitation. Crit Care Med 24:100910171996Crit Care Med 24:

24.

Ginsberg MD: The concept of the therapeutic window: a synthesis of critical issuesMoskowitz MACaplan LR (eds): Cerebrovascular Diseases: Nineteenth Princeton Stroke Conference. Boston: Butterworth-Heinemann1995331351Cerebrovascular Diseases: Nineteenth Princeton Stroke Conference.

25.

Ginsberg MDSternau LLGlobus MYTet al: Therapeutic modulation of brain temperature: relevance to ischemic brain injury. Cerebrovasc Brain Metab Rev 4:1892251992Cerebrovasc Brain Metab Rev 4:

26.

Gunn AJGunn TRde Haan HHet al: Dramatic neuronal rescue with prolonged selective head cooling after ischemia in fetal lambs. J Clin Invest 99:2482561997J Clin Invest 99:

27.

Haaland KSteen PAThoresen M: Cerebral, tympanic and colonic thermometry in the piglet. Reprod Fertil Dev 8:1251281996Reprod Fertil Dev 8:

28.

Hiyashi NHirayama TOhata M: The computed cerebral hypothermia management technique to the critical head injury patients. Adv Neurotrauma Res 5:61641993Adv Neurotrauma Res 5:

29.

Horn MSchlote WHenrich HA: Global cerebral ischemia and subsequent selective hypothermia. A neuropathological and morphometrical study on ischemic neuronal damage in cat. Acta Neuropathol 81:4434491991Acta Neuropathol 81:

30.

Huh PWBelayev LZhao Wet al: Comparative neuroprotective efficacy of prolonged moderate intraischemic and postischemic hypothermia in focal cerebral ischemia. J Neurosurg 92:91992000J Neurosurg 92:

31.

The Hypothermia After Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346:5495562002The Hypothermia After Cardiac Arrest Study Group: Mild therapeutic hypothermia to improve the neurologic outcome after cardiac arrest. N Engl J Med 346:

32.

Kissen ATHall JF JrKlemm FK: Physiological responses to cooling the head and neck versus the trunk and leg areas in severe hyperthermic exposure. Aerosp Med 42:8828881971Aerosp Med 42:

33.

Krieger DWDe Georgia MADevlin Tet al: Cooling acute ischemic brain damage (cool aid): a randomized pilot trial of endovascular cooling for patients with acute ischemic stroke. Stroke 34:2482003 (Abstract)Stroke 34:

34.

Kuhnen GBauer RWalter B: Controlled brain hypothermia by extracorporeal carotid blood cooling at normothermic trunk temperatures in pigs. J Neurosci Methods 89:1671741999J Neurosci Methods 89:

35.

Kuluz JWGregory GAYu ACHet al: Selective brain cooling during and after prolonged global ischemia reduces cortical damage in rats. Stroke 23:179217971992Stroke 23:

36.

Kuluz JWPrado RChang Jet al: Selective brain cooling increases cortical cerebral blood flow in rats. Am J Physiol 265:H824H8271993Am J Physiol 265:

37.

Kurz ASessler DILenhardt R: Perioperative normothermia to reduce the incidence of surgical-wound infection and shorten hospitalization. Study of Wound Infection and Temperature Group. N Engl J Med 334:120912151996N Engl J Med 334:

38.

Langer TNielsen BJessen C: Non-thermometric means of assessing cooling in humansMilton AS (ed): Temperature Regulation: Recent Physiological and Pharmacological Advances. Basel: Birkhaeuser Verlag1994145149Temperature Regulation: Recent Physiological and Pharmacological Advances.

39.

Laptook ARShalak LCorbett RJT: Differences in brain temperature and cerebral blood flow during selective head versus wholebody cooling. Pediatrics 108:110311102001Pediatrics 108:

40.

Leonov YSterz FSafar Pet al: Mild hypothermia during and after cardiac arrest improves neurologic outcome in dogs. J Cereb Blood Flow Metab 10:57701990J Cereb Blood Flow Metab 10:

41.

Lyden PNg KAl-Senani Fet al: Phase 1 study of endovascular-induced hypothermia in patients with acute ischemic stroke. Stroke 34:2492003 (Abstract)Stroke 34:

42.

Maher JHachinski V: Hypothermia as a potential treatment for cerebral ischemia. Cerebrovasc Brain Metab Rev 5:2773001993Cerebrovasc Brain Metab Rev 5:

43.

Maier CMSun GHKunis Det al: Delayed induction and longterm effects of mild hypothermia in a focal model of transient cerebral ischemia: neurological outcome and infarct size. J Neurosurg 94:90962001J Neurosurg 94:

44.

Marion DW: Cytokines and therapeutic hypothermia. Crit Care Med 30:166616672002 (Editorial)Marion DW: Cytokines and therapeutic hypothermia. Crit Care Med 30:

45.

Marion DWPenrod LEKelsey SFet al: Treatment of traumatic brain injury with moderate hypothermia. N Engl J Med 336:5405461997N Engl J Med 336:

46.

Markgraf CGClifton GLMoody MR: Treatment window for hypothermia in brain injury. J Neurosurg 95:9799832001J Neurosurg 95:

47.

Mellergard P: Changes in human intracerebral temperature in response to different methods of brain cooling. Neurosurgery 31:6716771992Mellergard P: Changes in human intracerebral temperature in response to different methods of brain cooling. Neurosurgery 31:

48.

Mellergard PNordstrom CH: Intracerebral temperature in neurosurgical patients. Neurosurgery 28:7097131991Neurosurgery 28:

49.

Natale JED'Alecy LG: Protection from cerebral ischemia by brain cooling without reduced lactate accumulation in dogs. Stroke 20:7707771989Stroke 20:

50.

Negrin J Jr: Selective local hypothermia in neurosurgery. NY State J Med 61:295129651961Negrin J Jr: Selective local hypothermia in neurosurgery. NY State J Med 61:

51.

Nunneley DATroutman SJ JrWebb P: Head cooling in work and heat stress. Aerosp Med 42:64681971Aerosp Med 42:

52.

Obrenovitch TP: The ischaemic penumbra: twenty years on. Cerebrovasc Brain Metab Rev 7:2973231995Obrenovitch TP: The ischaemic penumbra: twenty years on. Cerebrovasc Brain Metab Rev 7:

53.

Ohta TKuroiwa TSakaguchi Iet al: Selective hypothermic perfusion of canine brain. Neurosurgery 38:121112151996Neurosurgery 38:

54.

Ommaya AKBaldwin M: Direct extravascular brain cooling in the normothermic animal. Neurology 12:8828951962Neurology 12:

55.

Rumana CSGopinath SPUzura Met al: Brain temperature exceeds systemic temperature in head-injured patients. Crit Care Med 26:5625671998Crit Care Med 26:

56.

Safar P: Resuscitation of the ischemic brainAlbin MS (ed): Textbook of Neuroanesthesia: With Neurosurgical and Neuroscience Perspectives. New York: McGraw-Hill1997557593Textbook of Neuroanesthesia: With Neurosurgical and Neuroscience Perspectives.

57.

Schmied HKurz ASessler DIet al: Mild hypothermia increases blood loss and transfusion requirements during total hip arthroplasty. Lancet 347:2892921996Lancet 347:

58.

Schwab SSchwarz SAschoff Aet al: Moderate hypothermia and brain temperature in patients with severe middle cerebral artery infarction. Acta Neurochir Suppl 71:1311341998Acta Neurochir Suppl 71:

59.

Schwab SSpranger MAschoff Aet al: Brain temperature monitoring and modulation in patients with severe MCA infarction. Neurology 48:7627671997Neurology 48:

60.

Senning AOlsson PI: Changes in the vascular tonus during cerebral and regional hypothermia. Acta Chir Scand 112:2092191957Acta Chir Scand 112:

61.

Shvartz E: Effect of a cooling hood on physiological responses to work in a hot environment. J Appl Physiol 29:36391970Shvartz E: Effect of a cooling hood on physiological responses to work in a hot environment. J Appl Physiol 29:

62.

Sirimanne ESBlumberg RMBossano Det al: The effect of prolonged modification of cerebral temperature on outcome after hypoxic-ischemic brain injury in the infant rat. Pediatr Res 39:5915971996Pediatr Res 39:

63.

Sternau LThompson CDietrich WDet al: Intracranial temperature: observations in the human brain. J Cereb Blood Flow Metab 11 (Suppl 2):S1231991 (Abstract)J Cereb Blood Flow Metab 11 (Suppl 2):

64.

Tadler SCCallaway CWMenegazzi JJ: Noninvasive cerebral cooling in a swine model of cardiac arrest. Acad Emerg Med 5:25301998Acad Emerg Med 5:

65.

Takeda YNamba KHiguchi Tet al: Quantitative evaluation of the neuroprotective effects of hypothermia ranging from 34°C to 31°C on brain ischemia in gerbils and determination of the mechanism of neuroprotection. Crit Care Med 31:2552602003Crit Care Med 31:

66.

Thoresen MSimmonds MSatas Set al: Effective selective head cooling during posthypoxic hypothermia in newborn piglets. Pediatr Res 49:5945992001Pediatr Res 49:

67.

Wass CTWaggoner JR IIICable DGet al: Selective convective brain cooling during hypothermic cardiopulmonary bypass in dogs. Ann Thorac Surg 66:200820141998Ann Thorac Surg 66:

68.

Welsh FASims REHarris VA: Mild hypothermia prevents ischemic injury in gerbil hippocampus. J Cereb Blood Flow Metab 10:5575631990J Cereb Blood Flow Metab 10:

69.

White RJLocke GEAlbin MS: Isolated profound cerebral cooling with a bi-carotid heat exchanger shunt in dogs. Resuscitation 10:1931951983Resuscitation 10:

70.

Williams BAShitzer A: Modular liquid cooled helmet liner for thermal comfort. Aerospace Med 45:103010361974Aerospace Med 45:

71.

Zhu LDiao C: Theoretical simulation of temperature distribution in the brain during mild hypothermia treatment for brain injury. Med Biol Eng Comput 39:6816872001Med Biol Eng Comput 39:

TrendMD

Cited By

Metrics

Metrics

All Time Past Year Past 30 Days
Abstract Views 21 21 16
Full Text Views 124 124 43
PDF Downloads 75 75 14
EPUB Downloads 0 0 0

PubMed

Google Scholar