Multimodality Monitoring: Illuminating the Comatose Human Brain

Abstract

The field of neurocritical care has evolved tremendously in recent years, a development explained vastly by the advent of neurophysiological monitoring. From basic intracranial pressure measurements to brain tissue oxygenation, microdialysis, cerebral blood flow (CBF), and surface and intracortical electroencephalography (EEG), our ability to detect and control physiologic endpoints of brain function in comatose patients has grown substantially. The integration of these data gave birth to the concept of multimodality monitoring (MMM). Real-time data acquisition and analysis systems are crucial for fully understanding the relationship between physiologic drivers such as blood pressure, temperature and end-tidal CO₂, and end-point measures of brain metabolism such as brain tissue oxygen tension, CBF, lactate/pyruvate ratio, and EEG. Multimodality monitoring provides an early warning system for detecting physiological derangements that can be corrected before secondary brain injury occurs. Multimodality monitoring also allows for the creation of an optimized physiological environment for the injured brain, with the goal of preventing secondary injury events. The authors review the basic ideas and technical aspects of MMM, and therefore provide a unique window of illumination into the comatose human brain.

Keywords

multimodality monitoring - intracranial pressure - brain tissue oxygenation - microdialysis - cerebral blood flow - electroencephalography

• References

• 1 Riker RR, Fugate JE ; Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring. Clinical monitoring scales in acute brain injury: assessment of coma, pain, agitation, and delirium. Neurocrit Care 2014; 21 (2) (Suppl. 02) S27-S37
• 2 Monro A. Observations on the Structure and Functions of the Nervous System. London: William Creech and Joseph Johnson; 1823
• 3 Le Roux P, Menon DK, Citerio G , et al. Consensus summary statement of the International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care 2014; 21 (Suppl. 02) S1-S26
• 4 Badri S, Chen J, Barber J , et al. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med 2012; 38 (11) 1800-1809
• 5 Balestreri M, Czosnyka M, Hutchinson P , et al. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care 2006; 4 (1) 8-13
• 6 Treggiari MM, Schutz N, Yanez ND, Romand J-A. Role of intracranial pressure values and patterns in predicting outcome in traumatic brain injury: a systematic review. Neurocrit Care 2007; 6 (2) 104-112
• 7 Vik A, Nag T, Fredriksli OA , et al. Relationship of “dose” of intracranial hypertension to outcome in severe traumatic brain injury. J Neurosurg 2008; 109 (4) 678-684
• 8 Marmarou A, Eisenberg HM, Foulkes MA , et al. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. J Neurosurg 1991; 75: S59-S66
• 9 Fried HI, Nathan BR, Rowe AS , et al. The Insertion and Management of External Ventricular Drains: An Evidence-Based Consensus Statement: a statement for healthcare professionals from the Neurocritical Care Society. Neurocrit Care 2016; 24 (1) 61-81
• 10 Koskinen L-OD, Grayson D, Olivecrona M. The complications and the position of the Codman MicroSensor™ ICP device: an analysis of 549 patients and 650 Sensors. Acta Neurochir (Wien) 2013; 155 (11) 2141-2148 , discussion 2148
• 11 Poca M-A, Sahuquillo J, Arribas M, Báguena M, Amorós S, Rubio E. Fiberoptic intraparenchymal brain pressure monitoring with the Camino V420 monitor: reflections on our experience in 163 severely head-injured patients. J Neurotrauma 2002; 19 (4) 439-448
• 12 Stendel R, Heidenreich J, Schilling A , et al. Clinical evaluation of a new intracranial pressure monitoring device. Acta Neurochir (Wien) 2003; 145 (3) 185-193 , discussion 193
• 13 Koskinen L-OD, Olivecrona M. Clinical experience with the intraparenchymal intracranial pressure monitoring Codman MicroSensor system. Neurosurgery 2005; 56 (4) 693-698 , discussion 693–698
• 14 Citerio G, Piper I, Cormio M , et al; BrainIT Group. Bench test assessment of the new Raumedic Neurovent-P ICP sensor: a technical report by the BrainIT group. Acta Neurochir (Wien) 2004; 146 (11) 1221-1226
• 15 Sahuquillo J, Poca MA, Arribas M, Garnacho A, Rubio E. Interhemispheric supratentorial intracranial pressure gradients in head-injured patients: are they clinically important?. J Neurosurg 1999; 90 (1) 16-26
• 16 Griesdale DE , et al. Adherence to Guidelines for Management of Cerebral Perfusion Pressure and Outcome in Patients who have Severe Traumatic Brain Injury. 12th Annu Neurocritical Care Society Meet 2014;30:111–115
• 17 Chesnut RM, Temkin N, Carney N , et al; Global Neurotrauma Research Group. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 2012; 367 (26) 2471-2481
• 18 Chesnut RM, Bleck TP, Citerio G , et al. A consensus-based interpretation of the benchmark evidence from South American trials: treatment of intracranial pressure trial. J Neurotrauma 2015; 32 (22) 1722-1724
• 19 Le Roux P. Intracranial pressure after the BEST TRIP trial: a call for more monitoring. Curr Opin Crit Care 2014; 20 (2) 141-147
• 20 Feldman Z, Robertson CS. Monitoring of cerebral hemodynamics with jugular bulb catheters. Crit Care Clin 1997; 13 (1) 51-77
• 21 Chieregato A, Calzolari F, Trasforini G, Targa L, Latronico N. Normal jugular bulb oxygen saturation. J Neurol Neurosurg Psychiatry 2003; 74 (6) 784-786
• 22 Gopinath SP, Robertson CS, Contant CF , et al. Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry 1994; 57 (6) 717-723
• 23 Metz C, Holzschuh M, Bein T , et al. Monitoring of cerebral oxygen metabolism in the jugular bulb: reliability of unilateral measurements in severe head injury. J Cereb Blood Flow Metab 1998; 18 (3) 332-343
• 24 Le Roux PD, Oddo M. Parenchymal brain oxygen monitoring in the neurocritical care unit. Neurosurg Clin N Am 2013; 24 (3) 427-439
• 25 Ramakrishna R, Stiefel M, Udoetuk J , et al. Brain oxygen tension and outcome in patients with aneurysmal subarachnoid hemorrhage. J Neurosurg 2008; 109 (6) 1075-1082
• 26 Maloney-Wilensky E, Gracias V, Itkin A , et al. Brain tissue oxygen and outcome after severe traumatic brain injury: a systematic review. Crit Care Med 2009; 37 (6) 2057-2063
• 27 Oddo M, Levine JM, Mackenzie L , et al. Brain hypoxia is associated with short-term outcome after severe traumatic brain injury independently of intracranial hypertension and low cerebral perfusion pressure. Neurosurgery 2011; 69 (5) 1037-1045 , discussion 1045
• 28 Nangunoori R, Maloney-Wilensky E, Stiefel M , et al. Brain tissue oxygen-based therapy and outcome after severe traumatic brain injury: a systematic literature review. Neurocrit Care 2012; 17 (1) 131-138
• 29 Lin C-M, Lin M-C, Huang S-J , et al. A prospective randomized study of brain tissue oxygen pressure-guided management in moderate and severe traumatic brain injury patients. Biomed Res Int 2015; 2015: 529580
• 30 Martini RP, Deem S, Yanez ND , et al. Management guided by brain tissue oxygen monitoring and outcome following severe traumatic brain injury. J Neurosurg 2009; 111 (4) 644-649
• 31 Maas AIR, Citerio G. Noninvasive monitoring of cerebral oxygenation in traumatic brain injury: a mix of doubts and hope. Intensive Care Med 2010; 36 (8) 1283-1285
• 32 Oddo M, Bösel J. Monitoring of brain and systemic oxygenation in neurocritical care patients. Neurocrit Care 2014; 21: 103-120
• 33 Jaggi JL, Obrist WD, Gennarelli TA, Langfitt TW. Relationship of early cerebral blood flow and metabolism to outcome in acute head injury. J Neurosurg 1990; 72 (2) 176-182
• 34 Bouma GJ, Muizelaar JP, Choi SC, Newlon PG, Young HF. Cerebral circulation and metabolism after severe traumatic brain injury: the elusive role of ischemia. J Neurosurg 1991; 75 (5) 685-693
• 35 Vajkoczy P, Roth H, Horn P , et al. Continuous monitoring of regional cerebral blood flow: experimental and clinical validation of a novel thermal diffusion microprobe. J Neurosurg 2000; 93 (2) 265-274
• 36 Jaeger M, Soehle M, Schuhmann MU, Winkler D, Meixensberger J. Correlation of continuously monitored regional cerebral blood flow and brain tissue oxygen. Acta Neurochir (Wien) 2005; 147 (1) 51-56 , discussion 56
• 37 Willie CK, Tzeng Y-C, Fisher JA, Ainslie PN. Integrative regulation of human brain blood flow. J Physiol 2014; 592 (5) 841-859
• 38 Preiksaitis A, Krakauskaite S, Petkus V , et al. Association of severe traumatic brain injury patient outcomes with duration of cerebrovascular autoregulation impairment events. Neurosurgery 2016; 79: 75-82
• 39 Czosnyka M, Miller C ; Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring. Monitoring of cerebral autoregulation. Neurocrit Care 2014; 21 (Suppl. 02) S95-S102
• 40 Czosnyka M, Smielewski P, Kirkpatrick P, Laing RJ, Menon D, Pickard JD. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery 1997; 41 (1) 11-17 , discussion 17–19
• 41 Sorrentino E, Diedler J, Kasprowicz M , et al. Critical thresholds for cerebrovascular reactivity after traumatic brain injury. Neurocrit Care 2012; 16 (2) 258-266
• 42 Rosenthal G, Sanchez-Mejia RO, Phan N, Hemphill III JC, Martin C, Manley GT. Incorporating a parenchymal thermal diffusion cerebral blood flow probe in bedside assessment of cerebral autoregulation and vasoreactivity in patients with severe traumatic brain injury. J Neurosurg 2011; 114 (1) 62-70
• 43 de Lima Oliveira M, Kairalla AC, Fonoff ET, Martinez RC, Teixeira MJ, Bor-Seng-Shu E. Cerebral microdialysis in traumatic brain injury and subarachnoid hemorrhage: state of the art. Neurocrit Care 2014; 21 (1) 152-162
• 44 Galea JP, Tyrrell PJ, Patel HP, Vail A, King AT, Hopkins SJ. Pitfalls in microdialysis methodology: an in vitro analysis of temperature, pressure and catheter use. Physiol Meas 2014; 35 (3) N21-N28
• 45 M Dialysis AB Available at: http//www.mdialysis.com/clinical/neuro-intensive-care/products/products . Accessed September 6, 2016
• 46 Schneweis S, Grond M, Staub F , et al. Predictive value of neurochemical monitoring in large middle cerebral artery infarction. Stroke 2001; 32 (8) 1863-1867
• 47 Dohmen C, Bosche B, Graf R , et al. Identification and clinical impact of impaired cerebrovascular autoregulation in patients with malignant middle cerebral artery infarction. Stroke 2007; 38 (1) 56-61
• 48 Magnoni S, Tedesco C, Carbonara M, Pluderi M, Colombo A, Stocchetti N. Relationship between systemic glucose and cerebral glucose is preserved in patients with severe traumatic brain injury, but glucose delivery to the brain may become limited when oxidative metabolism is impaired: implications for glycemic control. Crit Care Med 2012; 40 (6) 1785-1791
• 49 Kurtz P, Claassen J, Schmidt JM , et al. Reduced brain/serum glucose ratios predict cerebral metabolic distress and mortality after severe brain injury. Neurocrit Care 2013; 19 (3) 311-319
• 50 Hashemi P, Bhatia R, Nakamura H , et al. Persisting depletion of brain glucose following cortical spreading depression, despite apparent hyperaemia: evidence for risk of an adverse effect of Leão's spreading depression. J Cereb Blood Flow Metab 2009; 29 (1) 166-175
• 51 Clausen T, Alves OL, Reinert M, Doppenberg E, Zauner A, Bullock R. Association between elevated brain tissue glycerol levels and poor outcome following severe traumatic brain injury. J Neurosurg 2005; 103 (2) 233-238
• 52 Chamoun R, Suki D, Gopinath SP, Goodman JC, Robertson C. Role of extracellular glutamate measured by cerebral microdialysis in severe traumatic brain injury. J Neurosurg 2010; 113 (3) 564-570
• 53 Westover MB, Shafi MM, Bianchi MT , et al. The probability of seizures during EEG monitoring in critically ill adults. Clin Neurophysiol 2015; 126 (3) 463-471
• 54 Claassen J, Taccone FS, Horn P, Holtkamp M, Stocchetti N, Oddo M ; Neurointensive Care Section of the European Society of Intensive Care Medicine. Recommendations on the use of EEG monitoring in critically ill patients: consensus statement from the neurointensive care section of the ESICM. Intensive Care Med 2013; 39 (8) 1337-1351
• 55 Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology 2004; 62 (10) 1743-1748
• 56 Claassen J, Vespa P ; Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring. Electrophysiologic monitoring in acute brain injury. Neurocrit Care 2014; 21 (2) (Suppl. 02) S129-S147
• 57 Foreman B, Claassen J. Quantitative EEG for the detection of brain ischemia. Crit Care 2012; 16 (2) 216
• 58 Rots ML, van Putten MJAM, Hoedemaekers CWE, Horn J. Continuous EEG monitoring for early detection of delayed cerebral ischemia in subarachnoid hemorrhage: a pilot study. Neurocrit Care 2016; 24 (2) 207-216
• 59 Kramer DR, Fujii T, Ohiorhenuan I, Liu CY. Cortical spreading depolarization: pathophysiology, implications, and future directions. J Clin Neurosci 2016; 24: 22-27
• 60 Waziri A, Claassen J, Stuart RM , et al. Intracortical electroencephalography in acute brain injury. Ann Neurol 2009; 66 (3) 366-377
• 61 Hemphill JC, Andrews P, De Georgia M. Multimodal monitoring and neurocritical care bioinformatics. Nat Rev Neurol 2011; 7 (8) 451-460
• 62 De Georgia MA, Kaffashi F, Jacono FJ, Loparo KA. Information technology in critical care: review of monitoring and data acquisition systems for patient care and research. ScientificWorldJournal 2015; 2015: 727694
• 63 Goldstein B, McNames J, McDonald BA , et al. Physiologic data acquisition system and database for the study of disease dynamics in the intensive care unit. Crit Care Med 2003; 31 (2) 433-441
• 64 Sivaganesan A, Manley GT, Huang MC. Informatics for neurocritical care: challenges and opportunities. Neurocrit Care 2014; 20 (1) 132-141