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The black box revelation

The black box revelation. What’s new in neuromonitoring?. Giuseppe Citerio. ! Water and the brain ! Monitoring. ! Conclusions. Capillary structure: central nervous system “BBB”. Adrogue HJ, Madias NE. Review article : HYPONATREMIA. N Engl J Med 2000 ; 342 : 1581-9. Distribution in brain

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The black box revelation

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  1. Theblackboxrevelation What’snewinneuromonitoring? GiuseppeCiterio

  2. !Waterandthebrain !Monitoring !Conclusions

  3. Capillarystructure:centralnervous system“BBB”

  4. AdrogueHJ,MadiasNE.Reviewarticle:HYPONATREMIA.NEnglJMed2000;342:1581-9.AdrogueHJ,MadiasNE.Reviewarticle:HYPONATREMIA.NEnglJMed2000;342:1581-9.

  5. Distributioninbrain ofaquaporin-1 (AQP1,blue) andAQP4 (orange) Amiry-Moghaddam,M.,&Ottersen,O.P.(2003).Themolecularbasisofwatertransportinthebrain.NatureReviewsNeuroscience,4(12),991–1001.doi:10.1038/nrn1252

  6. Architectureofthe aquaporin-1 Amiry-Moghaddam,M.,&Ottersen,O.P.(2003).Themolecularbasisofwatertransportinthebrain.NatureReviewsNeuroscience,4(12),991–1001.doi:10.1038/nrn1252

  7. Amiry-Moghaddam,M.,Frydenlund,D.S.,&Ottersen,O.P.(2004).AnchoringAmiry-Moghaddam,M.,Frydenlund,D.S.,&Ottersen,O.P.(2004).Anchoring ofaquaporin-4inbrain:molecularmechanismsandimplicationsforthe physiologyandpathophysiologyofwatertransport.Neuroscience,129(4), 999–1010.doi:10.1016/j.neuroscience.2004.08.049

  8. Postischemicedema(22hfollowing90minof MCAO) With aquaporins NO aquaporins Amiry-Moghaddam,M.,Frydenlund,D.S.,&Ottersen,O.P.(2004).Anchoring ofaquaporin-4inbrain:molecularmechanismsandimplicationsforthe physiologyandpathophysiologyofwatertransport.Neuroscience,129(4), 999–1010.doi:10.1016/j.neuroscience.2004.08.049

  9. ModifiedfromUnterberg,A(2004).Edemaand braintrauma.NSC,129(4),1021–1029.

  10. ModifiedfromUnterberg,A(2004).Edemaand braintrauma.NSC,129(4),1021–1029.

  11. Howtomonitorit?

  12. The“net”effect:increaseinvolume P ICP V LangfittTWetal,JNeurosurg,1964

  13. CTscanissuggestivebutcan’tmeasureit Normal Brainedema

  14. Invasivemonitoringsystems

  15. Oddsratiosofneurologicaloutcomesat1year, comparingintracranialpressure(ICP)patterns Oddsratiosand95%confidenceintervals[95%CI]ofneurologicaloutcomesat1 year,comparingintracranialpressure(ICP)patterns GlasgowOutcomeScore:GR,GoodRecovery;MD,ModerateDisability;SD,Severe Disability;V,Vegetative;D,Death Roleofintracranialpressurevaluesandpatternsinpredictingoutcomeintraumaticbraininjury:asystematicreview. Treggiari.NeurocritCare(2007)6:104–112

  16. patientswith(■)andwithout(☐)global cerebraledema(GCE) Helbok,R.,Ko,S.B.,Schmidt,J.M.,Kurtz,P.,Fernandez,L.,Choi,H.A.,Connolly,E.S.,etal.(2011).GlobalCerebralEdemaandBrainMetabolismAfterSubarachnoidHemorrhage. Stroke.doi:10.1161/STROKEAHA.110.604488

  17. Ultrasonographyofopticnervesheathdiameterfor detectionofraisedintracranialpressure Soldatos,T.,Chatzimichail,K.,Papathanasiou,M.,&Gouliamos,A.(2009).Optic nervesonography:anewwindowforthenon-invasiveevaluationofintracranial pressureinbraininjury.EmergencyMedicineJournal,26(9),630–634.doi:10.1136/ emj.2008.058453 Geeraerts,T.,Newcombe,V.F.J.,Coles,J.P.,Abate,M.G.,Perkes,I.E.,Hutchinson,P.J.A., Outtrim,J.G.,etal.(2008).UseofT2-weightedmagneticresonanceimagingoftheopticnerve sheathtodetectraisedintracranialpressure.Criticalcare(London,England),12(5),R114.doi: 10.1186/cc7006

  18. DubourgJUltrasonographyofopticnervesheathdiameterfordetectionDubourgJUltrasonographyofopticnervesheathdiameterfordetection ofraisedintracranialpressure:asystematicreviewandmeta-analysis. IntensiveCareMed.2011;37(7):1059–1068.

  19. Anewapproach Goldstein,B.,Tasker,R.C.,&Wakeland,W.(2012).FromLundbergtoSIM-ICP:ComputationalPhysiologyandModelingIntracranialPressure. Sciencetranslationalmedicine,4(129),129fs6.doi:10.1126/scitranslmed.3003925

  20. Kashif,F.M.,Verghese,G.C.,Novak,V.,Czosnyka,M.,&Heldt,T.(2012).Model-basednoninvasiveestimationofintracranialpressurefromcerebralbloodKashif,F.M.,Verghese,G.C.,Novak,V.,Czosnyka,M.,&Heldt,T.(2012).Model-basednoninvasiveestimationofintracranialpressurefromcerebralblood flowvelocityandarterialpressure.Sciencetranslationalmedicine,4(129),129ra44.doi:10.1126/scitranslmed.3003249

  21. (A)ICPandnICPon2665nonoverlapping windowsfrom45patientrecords. (B)ICPandnICPon1673nonoverlapping windowsfrom30recordswithbilateral CBFVrecordings, (C)ICPandnICPaveragedacrossall windowsineachof45patientrecords. Kashif,F.M.,Verghese,G.C.,Novak,V.,Czosnyka,M.,&Heldt,T.(2012).Model-basednoninvasiveestimationofintracranialpressurefromcerebralblood flowvelocityandarterialpressure.Sciencetranslationalmedicine,4(129),129ra44.doi:10.1126/scitranslmed.3003249

  22. Intracranialpressure Whenwatercontentincreases,volumeincreases. Therefore,ICPcouldrise. InvasiveICPmonitoring ✓Sensitivity:HIGH ✓Notspecific!!

  23. Braintissueoxygenation

  24. PbrO2andedema LeachRMandTreacherDFBMJ1998;317:1370-73 Moppett,I.K.,&Hardman,J.G.(2007).Modelingthecausesofvariationinbraintissueoxygenation. Anesthesia&Analgesia,105(4),1104–12–tableofcontents.doi:10.1213/01.ane.0000281934.99076.89

  25. patientswith(■)andwithout(☐)globalcerebraledema(GCE Helbok,R.,Ko,S.B.,Schmidt,J.M.,Kurtz,P.,Fernandez,L.,Choi,H.A.,Connolly,E.S.,etal.(2011).GlobalCerebralEdemaand BrainMetabolismAfterSubarachnoidHemorrhage.Stroke.doi:10.1161/STROKEAHA.110.604488

  26. Fletcher,J.J.,Bergman,K.,Blostein,P.A.,&Kramer,A.H.(2010).Fluidbalance,complications,andbraintissueoxygentensionFletcher,J.J.,Bergman,K.,Blostein,P.A.,&Kramer,A.H.(2010).Fluidbalance,complications,andbraintissueoxygentension monitoringfollowingseveretraumaticbraininjury.NeurocriticalCare,13(1),47–56.doi:10.1007/s12028-010-9345-2

  27. PbrO2 Whenwatercontentincreases,diffusivityofO2isdecreased. Therefore,PbrO2coulddecrease. PbrO2 !Sensitivity:MEDIUM !Notspecific!!

  28. Microdyalisis

  29. patientswith(■)andwithout(☐)globalcerebraledema(GCE Helbok,R.,Ko,S.B.,Schmidt,J.M.,Kurtz,P.,Fernandez,L.,Choi,H.A.,Connolly,E.S.,etal.(2011).GlobalCerebralEdemaand BrainMetabolismAfterSubarachnoidHemorrhage.Stroke.doi:10.1161/STROKEAHA.110.604488

  30. Microdyalisis Whenwatercontentincreases,ischemiacoulddevelop. Therefore,L/Pcouldincrease. L/P !Sensitivity:MEDIUM !Notspecific!!

  31. Howtoincreasespecificity?

  32. Lescot,T.,Bonnet,M.-P.,Zouaoui,A.,Muller,J.-C.,Fetita,C.,Coriat,P.,&Puybasset,L.(2005).Aquantitativecomputedtomographyassessmentofbrainweight,Lescot,T.,Bonnet,M.-P.,Zouaoui,A.,Muller,J.-C.,Fetita,C.,Coriat,P.,&Puybasset,L.(2005).Aquantitativecomputedtomographyassessmentofbrainweight, volume,andspecificgravityinsevereheadtrauma.IntensiveCareMedicine,31(8),1042–1050.doi:10.1007/s00134-005-2709-y

  33. Apparentdiffusioncoefficient-ADC H2O Cytotoxic Vasogenic

  34. Axialdiffusivity

  35. Axialdiffusivity

  36. ThermalDiffusionFlowmetry PassiveThermistor Activethermistor

  37. ThermalDiffusionFlowmetry 1mm •Determinationoftissue conduction=Thermal Conductivity[K-value]inbrain tissue •Extractionofconvection =heattransferwithinthefield •Calculationofperfusion =amountofpowertomaintain temperatureincrementof2-3 °Cabovebaseline Passive thermistor 8mm Active thermistor Temperature Measurementdiameter=8mm

  38. Ko,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).RealtimeestimationofbrainKo,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).Realtimeestimationofbrain watercontentincomatosepatients.AnnalsofNeurology,n/a–n/a.doi:10.1002/ana.23619

  39. Ko,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).RealtimeestimationofbrainKo,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).Realtimeestimationofbrain watercontentincomatosepatients.AnnalsofNeurology,n/a–n/a.doi:10.1002/ana.23619

  40. Ko,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).RealtimeestimationofbrainKo,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).Realtimeestimationofbrain watercontentincomatosepatients.AnnalsofNeurology,n/a–n/a.doi:10.1002/ana.23619

  41. !Waterinthebrainistightlycontrolled. !BrainedemaisassociatedwithHICPandworseoutcome !Increaseinwatercontentcouldbeevaluated(evenifNOT SPECIFIC)with: !ICP !PbrO2 !Microdyalisis !Imagingcouldhelpindefiningbrainedema !WatercontentinthebraincouldbemonitoredwithThermal DiffusionFlowmetry

  42. Thankyoufortheattention

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