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Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring

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Abstract

Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly—continuous, automated, and alarmed—evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.

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Abbreviations

AAS:

Ascending arousal (reticular activating) system

BAEP:

Brainstem auditory evoked potential

BR:

Blink reflex

CPP:

Cerebral perfusion pressure

CSF:

Cerebrospinal fluid

CT:

Computed tomography

EMG:

Electromyography

EP:

Evoked potential

ICP:

Intracranial pressure

IONM:

Intraoperative neurophysiological monitoring

MAP:

Mean arterial pressure

MBAEP:

Modified forms of the BAEP

MEP:

Motor evoked potentials

NCCU:

Neurocritical care unit

SOL:

Space-occupying lesion

SSEP:

Short latency somatosensory evoked potentials

sTBI:

Severe traumatic brain injury

TcE-MEP:

Transcranial electrical motor evoked potentials

TcM-MEP:

Transcranial magnetic motor evoked potentials

TrSSEP:

Trigeminal short latency somatosensory evoked potential

TTH:

Transtentorial herniation

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Acknowledgments

This work is dedicated to Dr. Robert A. Moody, a modern pioneer in the aggressive approach to cerebral decompression and ICP monitoring. In 1975, Dr. Moody established an experimental brain herniation laboratory at Chicago’s Cook County Hospital Hektoen Laboratory with the foresight to utilize the recently developed evoked potential responses. There, the senior author was stimulated to conduct experimental work. Special thanks to Dr. Jerome B. Posner of New York City, noted authority on ‘Stupor and Coma’ who graciously reviewed a draft of the manuscript, which he found of much interest, and met with the senior author to review the figures. We remain particularly grateful to Dr. John R. Hughes, our longtime mentor in clinical neurophysiology at the University of Illinois in Chicago (UIC). Dr. Gleb Gorelick, neuroradiologist at Advocate Illinois Masonic Hospital in Chicago assisted in interpretation of the MRI images, and Dr. Ankit Mehta, from the UIC Department of Neurosurgery, reviewed the manuscript and provided input. Finally, we thank our active clinical neurophysiology and intraoperative monitoring teams at both the UIC and Evanston/North Shore University Hospital for their continued enthusiasm and support.

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Authors and Affiliations

  1. Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA

    James L. Stone, Julian E. Bailes, Brian Sindelar & Vimal Patel

  2. Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA

    James L. Stone, Ahmed N. Hassan & John Fino

  3. Division of Neurosurgery, Department of Surgery, Cook County Stroger Hospital, Chicago, IL, USA

    James L. Stone

  4. Department of Neurosurgery, University of Florida, Gainesville, FL, USA

    Brian Sindelar

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Correspondence to James L. Stone.

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Conflict of interest

James L. Stone: Natus/Biologic provided evoked potential instrumentation and some technical support of work presented in this review. Patent issued to inventor JLS on 01/12/2014 and assigned and owned by the University of Illinois. Title: NonInvasive, Bedside Intra-Cranial Pressure And Brain Shift/Herniation Monitoring Unit Utilizing Early OnSet Auditory Evoked Responses. A University of Illinois start-up cooperation (Remote Vital Monitoring) has been formed and is in the early stages of development. Outside funding has not been obtained. JLS has 53 % stock ownership in this corporation. John Fino: A University of Illinois start-up corporation (Remote Vital Monitoring) has been formed and is in the early stages of development. Outside funding has not been secured. JF is a minor shareholder (5 % stock) in this corporation. Julian E. Bailes, Ahmed N. Hassan, Brian Sindelar, and Vimal Patel declare that they have no conflict of interest.

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Stone, J.L., Bailes, J.E., Hassan, A.N. et al. Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring. Neurocrit Care 26, 143–156 (2017). https://doi.org/10.1007/s12028-016-0298-y

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