Abstract
The challenges posed by acute brain injury (ABI) involve the management of the initial insult in addition to downstream inflammation, edema, and ischemia that can result in secondary brain injury (SBI). SBI is often subclinical, but can be detected through physiologic changes. These changes serve as a surrogate for tissue injury/cell death and are captured by parameters measured by various monitors that measure intracranial pressure (ICP), cerebral blood flow (CBF), brain tissue oxygenation (PbtO2), cerebral metabolism, and electrocortical activity. In the ideal setting, multimodality monitoring (MMM) integrates these neurological monitoring parameters with traditional hemodynamic monitoring and the physical exam, presenting the information needed to clinicians who can intervene before irreversible damage occurs. There are now consensus guidelines on the utilization of MMM, and there continue to be new advances and questions regarding its use. In this review, we examine these recommendations, recent evidence for MMM, and future directions for MMM.
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Marmarou A et al. Impact of ICP instability and hypotension on outcome in patients with severe head trauma. Spec Suppl. 1991;75:S59–66.
Narayan RK et al. Intracranial pressure: to monitor or not to monitor? A review of our experience with severe head injury. J Neurosurg. 1982;56:650–9.
Badri S et al. Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury. Intensive Care Med. 2012;38:1800–9.
Brain Trauma Foundation, American Association of Neurological Surgeons & Congress of Neurological Surgeons. Guidelines for the management of severe traumatic brain injury. J Neurotrauma. 2007;24 Suppl 1:S1–106.
Le Roux P et al. The International Multidisciplinary Consensus Conference on Multimodality Monitoring in Neurocritical Care: a list of recommendations and additional conclusions: a statement for healthcare professionals from the Neurocritical Care Society and the European Society of Intensive Care Medicine. Neurocrit Care. 2014;21 Suppl 2:S282–96. International, collaborative consensus statement on the use of physiologic bedside brain monitoring in ABI. Multidisciplinary experts in the field reviewed current literature on multiple MMM techniques in order to create evidence-based or expert-based practice guidelines.
Cremer OL et al. Effect of intracranial pressure monitoring and targeted intensive care on functional outcome after severe head injury. Crit Care Med. 2005;33:2207–13.
Chesnut RM et al. A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med. 2012;367:2471–81. Multicenter randomized controlled trial of 324 severe TBI patients comparing ICP treatment protocols utilizing parenchymal ICP monitoring compared to imaging and clinical examination alone as treatment triggers. No difference between two groups at 3- and 6-month follow-up in outcome and functional status.
Gerber LM, Chiu Y-L, Carney N, Härtl R, Ghajar J. Marked reduction in mortality in patients with severe traumatic brain injury. J Neurosurg. 2013;119:1583–90.
Alali AS et al. Intracranial pressure monitoring in severe traumatic brain injury: results from the American College of Surgeons Trauma Quality Improvement Program. J Neurotrauma. 2013;30:1737–46.
Talving P et al. Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study. J Neurosurg. 2013;119:1248–54.
Olson DM, Batjer HH, Abdulkadir K, Hall CE. Measuring and monitoring ICP in Neurocritical Care: results from a national practice survey. Neurocrit Care. 2014;20:15–20.
Bauer DF, Razdan SN, Bartolucci AA, Markert JM. Meta-analysis of hemorrhagic complications from ventriculostomy placement by neurosurgeons. Neurosurgery. 2011;69:255–60.
Helbok R, Olson DM, Le Roux PD, Vespa P, Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring. Intracranial pressure and cerebral perfusion pressure monitoring in non-TBI patients: special considerations. Neurocrit Care. 2014;21 Suppl 2:S85–94.
Liu H et al. External ventricular drains versus intraparenchymal intracranial pressure monitors in traumatic brain injury: a prospective observational study. World Neurosurg. 2015;83:794–800.
Webb AJS et al. Resolution of intraventricular hemorrhage varies by ventricular region and dose of intraventricular thrombolytic: the Clot Lysis: Evaluating Accelerated Resolution of IVH (CLEAR IVH) program. Stroke J Cereb Circ. 2012;43:1666–8.
Ziai WC et al. Occurrence and impact of intracranial pressure elevation during treatment of severe intraventricular hemorrhage. Crit Care Med. 2012;40:1601–8.
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;90:16–26.
Bekar A et al. Risk factors and complications of intracranial pressure monitoring with a fiberoptic device. J Clin Neurosci Off J Neurosurg Soc Australas. 2009;16:236–40.
Lescot T et al. In vivo accuracy of two intraparenchymal intracranial pressure monitors. Intensive Care Med. 2011;37:875–9.
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;6:104–12.
Bouzat P et al. Accuracy of brain multimodal monitoring to detect cerebral hypoperfusion after traumatic brain injury*. Crit Care Med. 2015;43:445–52. Prospective observational study on 27 severe TBI patients with MMM and its ability to predict low cerebral blood flow measured via perfusion CT. Combining ICP, PbtO2, and microdialysis provides more accurate detection of cerebral hypoperfusion than ICP monitoring alone.
Scalzo F, Bergsneider M, Vespa PM, Martin NA, Hu X. Intracranial pressure signal morphology: real-time tracking. IEEE Pulse. 2012;3:49–52.
Güiza F, Depreitere B, Piper I, Van den Berghe G, Meyfroidt G. Novel methods to predict increased intracranial pressure during intensive care and long-term neurologic outcome after traumatic brain injury: development and validation in a multicenter dataset. Crit Care Med. 2013;41:554–64.
Kristiansson H et al. Measuring elevated intracranial pressure through noninvasive methods: a review of the literature. J Neurosurg Anesthesiol. 2013;25:372–85.
Moreno JA et al. Evaluating the outcome of severe head injury with transcranial Doppler ultrasonography. Neurosurg Focus. 2000;8:e8.
Bellner J et al. Transcranial Doppler sonography pulsatility index (PI) reflects intracranial pressure (ICP). Surg Neurol. 2004;62:45–51. discussion 51.
Zweifel C et al. Reliability of the blood flow velocity pulsatility index for assessment of intracranial and cerebral perfusion pressures in head-injured patients. Neurosurgery. 2012;71:853–61.
Behrens A et al. Transcranial Doppler pulsatility index: not an accurate method to assess intracranial pressure. Neurosurgery. 2010;66:1050–7.
Rajajee V, Vanaman M, Fletcher JJ, Jacobs TL. Optic nerve ultrasound for the detection of raised intracranial pressure. Neurocrit Care. 2011;15:506–15.
Cammarata G et al. Ocular ultrasound to detect intracranial hypertension in trauma patients. J Trauma. 2011;71:779–81.
Bäuerle J, Lochner P, Kaps M, Nedelmann M. Intra- and interobsever reliability of sonographic assessment of the optic nerve sheath diameter in healthy adults. J Neuroimaging Off J Am Soc Neuroimaging. 2012;22:42–5.
Ballantyne SA, O’Neill G, Hamilton R, Hollman AS. Observer variation in the sonographic measurement of optic nerve sheath diameter in normal adults. Eur J Ultrasound Off J Eur Fed Soc Ultrasound Med Biol. 2002;15:145–9.
Chen JW et al. Pupillary reactivity as an early indicator of increased intracranial pressure: the introduction of the Neurological Pupil index. Surg Neurol Int. 2011;2:82.
Kosty JA et al. Brief report: a comparison of clinical and research practices in measuring cerebral perfusion pressure: a literature review and practitioner survey. Anesth Analg. 2013;117:694–8.
Andrews PJD et al. Predicting recovery in patients suffering from traumatic brain injury by using admission variables and physiological data: a comparison between decision tree analysis and logistic regression. J Neurosurg. 2002;97:326–36.
Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92:1–6.
Johnson U, Nilsson P, Ronne-Engström E, Howells T, Enblad P. Favorable outcome in traumatic brain injury patients with impaired cerebral pressure autoregulation when treated at low cerebral perfusion pressure levels. Neurosurgery. 2011;68:714–21. discussion 721–722.
Sviri GE, Aaslid R, Douville CM, Moore A, Newell DW. Time course for autoregulation recovery following severe traumatic brain injury. J Neurosurg. 2009;111:695–700.
Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg. 2001;95:560–8.
Robertson CS et al. Prevention of secondary ischemic insults after severe head injury. Crit Care Med. 1999;27:2086–95.
Eriksson EA et al. Cerebral perfusion pressure and intracranial pressure are not surrogates for brain tissue oxygenation in traumatic brain injury. Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2012;123:1255–60.
Czosnyka M et al. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery. 1997;41:11–7. discussion 17–19.
Aries MJH et al. Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med. 2012;40:2456–63.
Ko S-B et al. Multimodality monitoring for cerebral perfusion pressure optimization in comatose patients with intracerebral hemorrhage. Stroke J Cereb Circ. 2011;42:3087–92.
Steiner LA et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med. 2002;30:733–8.
Depreitere B et al. Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute monitoring data. J Neurosurg. 2014;120:1451–7.
Balestreri M et al. Impact of intracranial pressure and cerebral perfusion pressure on severe disability and mortality after head injury. Neurocrit Care. 2006;4:8–13.
Stewart C 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;63:1159–64. discussion 1164–1165.
Pennings FA, Schuurman PR, van den Munckhof P, Bouma GJ. Brain tissue oxygen pressure monitoring in awake patients during functional neurosurgery: the assessment of normal values. J Neurotrauma. 2008;25:1173–7.
Maloney-Wilensky E et al. Brain tissue oxygen and outcome after severe traumatic brain injury: a systematic review. Crit Care Med. 2009;37:2057–63.
Hlatky R, Valadka AB, Goodman JC, Contant CF, Robertson CS. Patterns of energy substrates during ischemia measured in the brain by microdialysis. J Neurotrauma. 2004;21:894–906.
Bohman L-E et al. Medical management of compromised brain oxygen in patients with severe traumatic brain injury. Neurocrit Care. 2011;14:361–9.
Bohman L-E et al. Response of brain oxygen to therapy correlates with long-term outcome after subarachnoid hemorrhage. Neurocrit Care. 2013;19:320–8.
Stiefel MF et al. Conventional neurocritical care and cerebral oxygenation after traumatic brain injury. J Neurosurg. 2006;105:568–75.
Jaeger M, Schuhmann MU, Soehle M, Nagel C, Meixensberger J. Continuous monitoring of cerebrovascular autoregulation after subarachnoid hemorrhage by brain tissue oxygen pressure reactivity and its relation to delayed cerebral infarction. Stroke J Cereb Circ. 2007;38:981–6.
Rosenthal G et al. Brain tissue oxygen tension is more indicative of oxygen diffusion than oxygen delivery and metabolism in patients with traumatic brain injury. Crit Care Med. 2008;36:1917–24.
Ulrich CT et al. Occurrence of vasospasm and infarction in relation to a focal monitoring sensor in patients after SAH: placing a bet when placing a probe? PLoS ONE. 2013;8, e62754.
Gok F, Kilicaslan A, Yosunkaya A. Ultrasound-guided jugular bulb catheterisation in the intensive care unit. Anaesth Intensive Care. 2014;42:523–4.
Sheinberg M et al. Continuous monitoring of jugular venous oxygen saturation in head-injured patients. J Neurosurg. 1992;76:212–7.
Gopinath SP et al. Jugular venous desaturation and outcome after head injury. J Neurol Neurosurg Psychiatry. 1994;57:717–23.
Le Roux PD, Newell DW, Lam AM, Grady MS, Winn HR. Cerebral arteriovenous oxygen difference: a predictor of cerebral infarction and outcome in patients with severe head injury. J Neurosurg. 1997;87:1–8.
Cormio M, Valadka AB, Robertson CS. Elevated jugular venous oxygen saturation after severe head injury. J Neurosurg. 1999;90:9–15.
Gupta AK et al. Measuring brain tissue oxygenation compared with jugular venous oxygen saturation for monitoring cerebral oxygenation after traumatic brain injury. Anesth Analg. 1999;88:549–53.
Stiefel MF et al. Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring. J Neurosurg. 2005;103:805–11.
Davies DJ et al. Near-infrared spectroscopy in the monitoring of adult traumatic brain injury: a review. J Neurotrauma. 2015;32:933–41.
Miller C, Armonda R, Participants in the International Multi-disciplinary Consensus Conference on Multimodality Monitoring. Monitoring of cerebral blood flow and ischemia in the critically ill. Neurocrit Care. 2014;21 Suppl 2:S121–8.
Vora, null, Suarez-Almazor, null, Steinke, null, Martin, null & Findlay, null. Role of transcranial Doppler monitoring in the diagnosis of cerebral vasospasm after subarachnoid hemorrhage. Neurosurgery 1999;44:1237–1247; discussion 1247–1248.
Suarez JI et al. Symptomatic vasospasm diagnosis after subarachnoid hemorrhage: evaluation of transcranial Doppler ultrasound and cerebral angiography as related to compromised vascular distribution. Crit Care Med. 2002;30:1348–55.
Gonzalez NR, Boscardin WJ, Glenn T, Vinuela F, Martin NA. Vasospasm probability index: a combination of transcranial doppler velocities, cerebral blood flow, and clinical risk factors to predict cerebral vasospasm after aneurysmal subarachnoid hemorrhage. J Neurosurg. 2007;107:1101–12.
Nakae R, Yokota H, Yoshida D, Teramoto A. Transcranial Doppler ultrasonography for diagnosis of cerebral vasospasm after aneurysmal subarachnoid hemorrhage: mean blood flow velocity ratio of the ipsilateral and contralateral middle cerebral arteries. Neurosurgery. 2011;69:876–83. discussion 883.
Carrera E et al. Transcranial Doppler for predicting delayed cerebral ischemia after subarachnoid hemorrhage. Neurosurgery. 2009;65:316–23. discussion 323–324.
Proust F et al. Usefulness of transcranial color-coded sonography in the diagnosis of cerebral vasospasm. Stroke J Cereb Circ. 1999;30:1091–8.
Sioutos PJ et al. Continuous regional cerebral cortical blood flow monitoring in head-injured patients. Neurosurgery. 1995;36:943–9. discussion 949–950.
Vajkoczy P et al. Continuous monitoring of regional cerebral blood flow: experimental and clinical validation of a novel thermal diffusion microprobe. J Neurosurg. 2000;93:265–74.
Bhatia A, Gupta AK. Neuromonitoring in the intensive care unit. I. Intracranial pressure and cerebral blood flow monitoring. Intensive Care Med. 2007;33:1263–71.
Vajkoczy P, Horn P, Thome C, Munch E, Schmiedek P. Regional cerebral blood flow monitoring in the diagnosis of delayed ischemia following aneurysmal subarachnoid hemorrhage. J Neurosurg. 2003;98:1227–34.
Claassen J, Mayer SA, Kowalski RG, Emerson RG, Hirsch LJ. Detection of electrographic seizures with continuous EEG monitoring in critically ill patients. Neurology. 2004;62:1743–8.
DeLorenzo RJ et al. Persistent nonconvulsive status epilepticus after the control of convulsive status epilepticus. Epilepsia. 1998;39:833–40.
Chen JWY, Wasterlain CG. Status epilepticus: pathophysiology and management in adults. Lancet Neurol. 2006;5:246–56.
Vespa PM et al. Early detection of vasospasm after acute subarachnoid hemorrhage using continuous EEG ICU monitoring. Electroencephalogr Clin Neurophysiol. 1997;103:607–15.
Claassen J et al. Quantitative continuous EEG for detecting delayed cerebral ischemia in patients with poor-grade subarachnoid hemorrhage. Clin Neurophysiol Off J Int Fed Clin Neurophysiol. 2004;115:2699–710.
Claassen J et al. Nonconvulsive seizures after subarachnoid hemorrhage: multimodal detection and outcomes. Ann Neurol. 2013;74:53–64.
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 Suppl 2:S129–47.
Stuart RM et al. Intracranial multimodal monitoring for acute brain injury: a single institution review of current practices. Neurocrit Care. 2010;12:188–98.
Stuart RM et al. Intracortical EEG for the detection of vasospasm in patients with poor-grade subarachnoid hemorrhage. Neurocrit Care. 2010;13:355–8.
Reinstrup P et al. Intracerebral microdialysis in clinical practice: baseline values for chemical markers during wakefulness, anesthesia, and neurosurgery. Neurosurgery. 2000;47:701–9. discussion 709–710.
Timofeev I et al. Cerebral extracellular chemistry and outcome following traumatic brain injury: a microdialysis study of 223 patients. Brain J Neurol. 2011;134:484–94.
Hutchinson P, O’Phelan K, Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring. International multidisciplinary consensus conference on multimodality monitoring: cerebral metabolism. Neurocrit Care. 2014;21 Suppl 2:S148–58.
Vespa PM et al. Pericontusional brain tissue exhibits persistent elevation of lactate/pyruvate ratio independent of cerebral perfusion pressure. Crit Care Med. 2007;35:1153–60.
Vespa P et al. Metabolic crisis without brain ischemia is common after traumatic brain injury: a combined microdialysis and positron emission tomography study. J Cereb Blood Flow Metab Off J Int Soc Cereb Blood Flow Metab. 2005;25:763–74.
Sala N et al. Cerebral extracellular lactate increase is predominantly nonischemic in patients with severe traumatic brain injury. J Cereb Blood Flow Metab Off J Int Soc Cereb Blood Flow Metab. 2013;33:1815–22. Prospective observational study of 24 patients with severe TBI with MMM and perfusion CT. Elevations in lactate were found primarily in non-hypoxic periods suggesting glycolytic pathway to elevated lactate formation.
Schmidt JM, De Georgia M, Participants in the International Multidisciplinary Consensus Conference on Multimodality Monitoring. Multimodality monitoring: informatics, integration data display and analysis. Neurocrit Care. 2014;21 Suppl 2:S229–38.
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David Roh declares that he has no conflict of interest.
Soojin Park reports grants from National Institutes of Health K01-ES026833.
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Roh: Acquisition of data, analysis and interpretation, draft of the manuscript, and critical revision of the manuscript for important intellectual content.
Park: Critical revision of the manuscript for important intellectual content.
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SP is supported by the National Institute of Environmental Health Sciences of the National Institutes of Health under Award Number K01ES026833. The content is solely the responsibility of the authors and does not necessarily represent the official views of the National Institutes of Health.
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Roh, D., Park, S. Brain Multimodality Monitoring: Updated Perspectives. Curr Neurol Neurosci Rep 16, 56 (2016). https://doi.org/10.1007/s11910-016-0659-0
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DOI: https://doi.org/10.1007/s11910-016-0659-0