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Intracranial Multimodal Monitoring for Acute Brain Injury: A Single Institution Review of Current Practices

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Abstract

Background

Critical care management of patients with severe acute brain injury has undergone tremendous advances. Neurosurgeons and neurointensivists have a large armamentarium of invasive monitoring devices available to help detect secondary brain injury and guide therapy. No consensus exists regarding patient specific selection of monitoring devices, the placement of devices in relation to injured brain tissue, or the preferred insertion technique. Here we review our experience in a consecutive series of acutely brain injured patients who underwent multimodality monitoring.

Methods

Sixty-one patients admitted to the Neurological Intensive Care Unit underwent multimodality intracranial monitoring between January 2005 and October 2008. Patient demographics, hospital length of stay, types of monitoring devices and modalities monitored, insertion techniques, device placement location relative to injury, and complications are reported.

Results

Monitored modalities included brain tissue oxygen (PbtO2) in 97% (N = 59), microdialysis (MD) in 79% (N = 48), intracranial electroencephalography in 31% (N = 19), brain temperature in 18% (N = 11), and cerebral blood flow in 11% (N = 7). On average, monitoring started within 2 days (0–8) of admission and was continued for 7 days (1–17). The majority of probes (56%; N = 35) were placed into patients with focal brain injuries, while in 43% N = 26 the injury was diffuse. Among those with focal injury, probe placement was categorized as peri-lesional in 46% (N = 16), and within a clot or infarct in 17% (N = 6). The most frequent complication of multimodality brain monitoring was device malfunction or dislodgement (43%; N = 26). Rates of hematoma and infection were 3 and 5%, respectively. Average NICU length of stay was 17 days (3–48) and 26% (N = 16) of patients were dead at discharge.

Conclusions

Collaboration among institutions is necessary to establish practice guidelines for the choice and placement of multimodal monitors. Further advancement in device technology is needed to improve insertion techniques, inter-device compatibility, and device durability. Multimodality data needs to be analyzed to determine the preferable device location.

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References

  1. Bardt TF, Unterberg AW, Kiening KL, Schneider GH, Lanksch WR. Multimodal cerebral monitoring in comatose head-injured patients. Acta Neurochir (Wien). 1998;140(4):357–65.

    Article  CAS  Google Scholar 

  2. De Georgia MA, Deogaonkar A. Multimodal monitoring in the neurological intensive care unit. Neurologist. 2005;11(1):45–54.

    Article  PubMed  Google Scholar 

  3. Kirkpatrick PJ, Czosnyka M, Pickard JD. Multimodal monitoring in neurointensive care. J Neurol Neurosurg Psychiatry. 1996;60(2):131–9.

    Article  CAS  PubMed  Google Scholar 

  4. Meixensberger J, Jager A, Dings J, Baunach S, Roosen K. Multimodal hemodynamic neuromonitoring–quality and consequences for therapy of severely head injured patients. Acta Neurochir Suppl. 1998;71:260–2.

    CAS  PubMed  Google Scholar 

  5. Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28(5):547–53.

    Article  PubMed  Google Scholar 

  6. Simons R, Eliopoulos V, Laflamme D, Brown DR. Impact on process of trauma care delivery 1 year after the introduction of a trauma program in a provincial trauma center. J Trauma. 1999;46(5):811–5. (discussion 5–6).

    Article  CAS  PubMed  Google Scholar 

  7. Spain DA, McIlvoy LH, Fix SE, Carrillo EH, Boaz PW, Harpring JE, et al. Effect of a clinical pathway for severe traumatic brain injury on resource utilization. J Trauma. 1998;45(1):101–4. (discussion 4–5).

    Article  CAS  PubMed  Google Scholar 

  8. Springborg JB, Frederiksen HJ, Eskesen V, Olsen NV. Trends in monitoring patients with aneurysmal subarachnoid haemorrhage. Br J Anaesth. 2005;94(3):259–70.

    Article  CAS  PubMed  Google Scholar 

  9. Steiner T, Pilz J, Schellinger P, Wirtz R, Friederichs V, Aschoff A, et al. Multimodal online monitoring in middle cerebral artery territory stroke. Stroke. 2001;32(11):2500–6.

    Article  CAS  PubMed  Google Scholar 

  10. Unterberg AW, Kiening KL, Hartl R, Bardt T, Sarrafzadeh AS, Lanksch WR. Multimodal monitoring in patients with head injury: evaluation of the effects of treatment on cerebral oxygenation. J Trauma. 1997;42(5 Suppl):S32–7.

    Article  CAS  PubMed  Google Scholar 

  11. Czosnyka M, Guazzo E, Iyer V, Kirkpatrick P, Smielewski P, Whitehouse H, et al. Testing of cerebral autoregulation in head injury by waveform analysis of blood flow velocity and cerebral perfusion pressure. Acta Neurochir Suppl (Wien). 1994;60:468–71.

    CAS  Google Scholar 

  12. Czosnyka M, Guazzo E, Whitehouse M, Smielewski P, Czosnyka Z, Kirkpatrick P, et al. Significance of intracranial pressure waveform analysis after head injury. Acta Neurochir (Wien). 1996;138(5):531–41. discussion 41–2.

    Article  CAS  Google Scholar 

  13. Czosnyka M, Kirkpatrick PJ, Pickard JD. Multimodal monitoring and assessment of cerebral haemodynamic reserve after severe head injury. Cerebrovasc Brain Metab Rev. 1996;8(4):273–95.

    CAS  PubMed  Google Scholar 

  14. Czosnyka M, Pickard J, Whitehouse H, Piechnik S. The hyperaemic response to a transient reduction in cerebral perfusion pressure. A modelling study. Acta Neurochir (Wien). 1992;115(3–4):90–7.

    Article  CAS  Google Scholar 

  15. Dings J, Jager A, Meixensberger J, Roosen K. Brain tissue pO2 and outcome after severe head injury. Neurol Res. 1998;20(Suppl 1):S71–5.

    PubMed  Google Scholar 

  16. Dings J, Meixensberger J, Jager A, Roosen K. Clinical experience with 118 brain tissue oxygen partial pressure catheter probes. Neurosurgery. 1998;43(5):1082–95.

    Article  CAS  PubMed  Google Scholar 

  17. Mack WJ, King RG, Ducruet AF, Kreiter K, Mocco J, Maghoub A, et al. Intracranial pressure following aneurysmal subarachnoid hemorrhage: monitoring practices and outcome data. Neurosurg Focus. 2003;14(4):e3.

    Article  PubMed  Google Scholar 

  18. Rumana CS, Gopinath SP, Uzura M, Valadka AB, Robertson CS. Brain temperature exceeds systemic temperature in head-injured patients. Crit Care Med. 1998;26(3):562–7.

    Article  CAS  PubMed  Google Scholar 

  19. Stewart C, Haitsma I, Zador Z, Hemphill JC III, Morabito D, Manley G III, et al. The new Licox combined brain tissue oxygen and brain temperature monitor: assessment of in vitro accuracy and clinical experience in severe traumatic brain injury. Neurosurgery. 2008;63(6):1159–64. (discussion 64–65).

    Article  PubMed  Google Scholar 

  20. Waziri AE, Oddo M, Schmidt JM, Claassen J, Parra A, Badjatia N, et al. Early experience with a cortical depth electrode for ICU neurophysiological monitoring. Epilepsia. 2007;48(Suppl 6):208–9.

    Google Scholar 

  21. Gallagher CN, Carpenter KL, Grice P, Howe DJ, Mason A, Timofeev I, et al. The human brain utilizes lactate via the tricarboxylic acid cycle: a 13C-labelled microdialysis and high-resolution nuclear magnetic resonance study. Brain. 2009;132(Pt 10):2839–49.

    Article  PubMed  Google Scholar 

  22. Hlatky R, Furuya Y, Valadka AB, Robertson CS. Management of cerebral perfusion pressure. Semin Respir Crit Care Med. 2001;22(1):3–12.

    Article  CAS  PubMed  Google Scholar 

  23. Radolovich DK, Czosnyka M, Timofeev I, Lavinio A, Hutchinson P, Gupta A, et al. Reactivity of brain tissue oxygen to change in cerebral perfusion pressure in head injured patients. Neurocrit Care. 2009;10(3):274–9.

    Article  CAS  PubMed  Google Scholar 

  24. Office of Medical Applications of Research, National Institutes of Health. Fresh frozen plasma: indications and risks. JAMA. 1985;253(4):551–3.

    Article  Google Scholar 

  25. Practice parameter for the use of fresh-frozen plasma, cryoprecipitate, and platelets. Fresh-frozen plasma, cryoprecipitate, and platelets administration practice guidelines development Task Force of the College of American Pathologists. JAMA. 1994;271(10):777–81.

    Google Scholar 

  26. Hunt WE, Hess RM. Surgical risk as related to time of intervention in the repair of intracranial aneurysms. J Neurosurg. 1968;28(1):14–20.

    Article  CAS  PubMed  Google Scholar 

  27. Garner JS, Jarvis WR, Emori TG, Horan TC, Hughes JM. CDC definitions for nosocomial infections, 1988. Am J Infect Control. 1988;16(3):128–40.

    Article  CAS  PubMed  Google Scholar 

  28. Birch AA, Eynon CA, Schley D. Erroneous intracranial pressure measurements from simultaneous pressure monitoring and ventricular drainage catheters. Neurocrit Care. 2006;5(1):51–4.

    Article  CAS  PubMed  Google Scholar 

  29. Engstrom M, Polito A, Reinstrup P, Romner B, Ryding E, Ungerstedt U, et al. Intracerebral microdialysis in severe brain trauma: the importance of catheter location. J Neurosurg. 2005;102(3):460–9.

    Article  PubMed  Google Scholar 

  30. Vespa PM, O’Phelan K, McArthur D, Miller C, Eliseo M, Hirt D, et al. Pericontusional brain tissue exhibits persistent elevation of lactate/pyruvate ratio independent of cerebral perfusion pressure. Crit Care Med. 2007;35(4):1153–60.

    Article  PubMed  Google Scholar 

  31. Frontera JA, Fernandez A, Schmidt JM, Claassen J, Wartenberg KE, Badjatia N, et al. Impact of nosocomial infectious complications after subarachnoid hemorrhage. Neurosurgery. 2008;62(1):80–7.

    Article  PubMed  Google Scholar 

  32. Lozier AP, Sciacca RR, Romagnoli MF, Connolly ESJ. Ventriculostomy-related infections: a critical review of the literature. Neurosurgery. 2008;62(Suppl 2):688–700.

    PubMed  Google Scholar 

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Correspondence to Jan Claassen.

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Stuart, R.M., Schmidt, M., Kurtz, P. et al. Intracranial Multimodal Monitoring for Acute Brain Injury: A Single Institution Review of Current Practices. Neurocrit Care 12, 188–198 (2010). https://doi.org/10.1007/s12028-010-9330-9

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