In The News 2018-01-08T18:08:40+00:00

Vittamed News

Publications & Abstracts

Monitoring and Prevention of Brain Injury during Cardiac Surgery using Vittamed non-invasive Cerebral Autoregulation monitor 2017-12-15T18:35:37+00:00

Authors:

Ragauskas Arminas1, Petkus Vytautas1, Birutė Kumpaitienė2, Milda Švagždienė2,3, Romanas Chomskis1, Edmundas Sirvinskas2,3

 

Institutions:

  1. Telematics Scientific Laboratory, Kaunas University of Technology, Studentu 50-450A, Kaunas, Lithuania.
  2. Clinic of Cardiothoracic and vascular surgery, Kaunas Hospital of Lithuanian University of Health Sciences, Eiveniu 2, Kaunas
  3. Institute of Cardiology, Lithuanian University of Health Sciences, Sukileliu 17, Kaunas

 

OBJECTIVES

Post-operative cognitive dysfunction (POCD) after cardiac surgery occurs in up to 80–90 % of cases in early postoperative period and their incidence still remains high after 3 months (~ 40 %) and 1 year (~ 25 %). Our hypothesis is that POCD could be related to impaired Cerebral Blood Flow Autoregulation (CA). We propose the non-invasively technique for monitoring of individual patient specific CA in order to prevent brain insults and cognitive dysfunctions.

METHOD

“Vittamed” non-invasive CA monitor was used for testing of our hypothesis on cardiac surgery patients. CA was estimated by calculating pressure reactivity index PRx as correlation coefficient between slow waves of mean arterial pressure (MAP) and non-invasively measured slow waves of intracranial blood volume.

RESULTS

The deterioration of CA lasting up to 6 min was observed when MAP temporarily dipped below the lowest physiological CA threshold during cardiac surgery (Fig.1). ). When MAP was immediately returned to >60mmHg  CA normal status returned slowly. We hypothesize that such episodes could be associated with the risk of POCD and “secondary brain insult”. Further investigations are needed to test this hypothesis.

 

CONCLUSIONS

“Vittamed” non-invasive CA monitor can be used for individual patient specific MAP management during the cardiac surgery in order to prevent brain injuries and cognitive dysfunctions.

Fig. 1. Case of CA monitoring during patient’s cardiac surgery. Drop of MAP below lowest patient specific CA critical threshold causes the impairment of CA (PRx>0) and a “secondary brain insults”.

Non-invasive cerebral autoregulation monitoring during cardiac surgery with cardiopulmonary bypass. 2017-12-12T22:23:16+00:00

R. Zakelis1, B. Kumpaitiene2, S. Krakauskaite1, V. Petkus1, R. Chomskis1, M. Svagzdiene2,3,E. Sirvinskas2,3, R. Benetis2,3,R. Ragauskas1

1Health Telematics Science Institute, Kaunas University of Technology, Kaunas,

Lithuania

2Clinic of Cardiothoracic and Vascular Surgery, Kaunas Hospital of Lithuanian University

of Health Sciences, Kaunas, Lithuania

3Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania

 

Objectives

Post-operative cognitive dysfunction (POCD) following cardiac surgery with a cardiopulmonary bypass (CPB) can be related to a temporal cerebral hypoperfusion and impaired cerebrovascular autoregulation (CA). Objective is to validate prospectively the innovative non-invasive CA monitoring technology for patient-specific mean arterial blood pressure (MAP) management in order to prevent POCD.

 

Materials and Methods

The ongoing study included 59 patients undergoing the CPB surgery. All patients were ASA III class, NYHA III class. Their age limits were 47 – 87 years. The “Vittamed505” noninvasive CA monitor based on the intracranial blood volume (IBV) measurement within small arterial vessels and arterioleswas used during surgery. The CA status was estimated continuously by calculating the pressure reactivity index vPRx(t) as a phase shift between the slow waves of MAP(t) and IBV(t) The neuropsychological tests were performed before and 10 days after CPB surgery for each patient in order to estimate changes of mental abilities and detect POCD.

 

Results

Results of prospective clinical trial: 34 patients without post-operative deterioration, 14 patients with deteriorated mental abilities and 11 patients with POCD. Duration of longest cerebral autoregulation impairment (LCAI) event above critical 240 sec threshold when vPRx>0 is associated with deteriorated mental abilities and POCD (Fig. 1)

 

Conclusions

The preliminary study showed that the duration of LCAI event during CPB surgery is associated with deteriorated mental abilities and risk of POCD. The „Vittamed505” noninvasive CA monitor can be used for the patient-specific MAP management during cardiac CPB surgery in order to prevent cognitive dysfunctions.

 

Acknowledgement: This research has been funded by the grant MIP-022/2014 from the Research Council of Lithuania.

Figure 1. Results of prospective clinical trial of 59 CPB patients. Duration of LCAI event above critical 240 sec threshold (green line) is associated with deteriorated mental abilities and POCD (2 =4.11, p=0.042).

Prospective comparative clinical study of non-invasive cerebrovascular autoregulation monitor. 2017-12-12T22:21:23+00:00

V. Petkus1, R. Zakelis1, S. Krakauskaite1, A. Preiksaitis2, R. Chomskis1, S. Rocka2, A. Ragauskas1,

1Health Telematics Science Institute, Kaunas University of Technology, Lithuania.

2 Republic’s Vilnius University Hospital, Vilnius University, Clinics of Neurology and Neurosurgery, Lithuania.

 

Introduction: Application of existing non-invasive cerebrovascular autoregulation (CA) monitoring technologies in ICU still remains complicated due to the necessity to perform long-term and continuous CA assessment.

 

Objectives: to investigate the innovative non-invasive CA monitoring technology by exploring its applicability for CA status diagnosing in the traumatic brain injury (TBI) patients.

 

Materials & Methods: The non-invasive CA monitor “Vittamed 505” is based on the ultrasonic transintracranial “time-of-flight” measurement of intracranial blood volume (IBV) fluctuations within the brain parenchyma. Non-invasive CA index (vPRx) is calculated according to the phase difference between the slow waves of IBV and reference arterial blood pressure signal.

 

Results: The CA status was monitored for 42 severe TBI patients by comparing non-invasively and invasively measured Pressure Reactivity indexes (PRx). The obtained correlation between the indexes was r=0.71, standard deviation of difference between the indexes was SD=0.254, total monitoring time was 56 h.

 

Conclusion: The proposed non-invasive CA real-time monitoring technology provides the same diagnostic information as the invasive methods and can be used for long-term patients monitoring in ICU.

 

Acknowledgement: The research was funded by the grant MIP-087/2015 from the Research Council of Lithuania.

Prospective Comparative Clinical Study of Non-Invasive Cerebrovascular Autoregulation Monitor 2017-12-12T22:20:49+00:00

Synopsis

Presented is the prospective clinical study of novel non-invasive cerebrovascular autoregulation monitoring technology. The study was carried out in Republic’s Vilnius University Hospital (Lithuania) by performing continuous comparative cerebrovascular autoregulation status measurement with non-invasive and invasive technologies based on Pressure Reactivity index calculation. The results of 42 severe comatose traumatic brain injury patients’ monitoring showed significant agreement between the invasive and non-invasive cerebrovascular autoregulation indexes (r=0.71), thus showing applicability of presented non-invasive cerebrovascular autoregulation monitoring technology for long-term traumatic brain injury patients’ monitoring in ICU.

 

Target audience

Application of existing non-invasive cerebrovascular autoregulation (CA) monitoring technologies in ICU remain complicated due to the necessity to perform long-term and continuous CA assessment. The impairment of CA has a strong impact on the outcome of the traumatic brain injury (TBI) patients, therefore it is essential to know the real-time status of CA [1,2]. Even temporal CA failure is associated with worse outcomes of TBI patients [3].

 

Purpose

The aim of the study was to investigate the innovative non-invasive CA monitoring technology by exploring it’s applicability for continuous CA status diagnosing in the TBI patients.

 

Methods

The innovative non-invasive CA monitor “Vittamed 505” was used for clinical assessment by comparing to invasive CA monitoring approaches based on Pressure Reactivity index (PRx) calculation. The non-invasive CA monitor is based on the ultrasonic transintracranial “time-of-flight” measurement of intracranial blood volume (IBV) fluctuations [4]. The head frame with ultrasonic transducers are mounted to the human head to fix transducers in the position ensuring ultrasound wave transmission through the brain parenchyma tissue that contain mainly small parenchymal vessels and arterioles. The non-invasive CA status index (vPRx) calculation is based on the phase difference between the slow waves of IBV and reference arterial blood pressure (ABP) signal. The invasive PRx index as a “gold standard” estimate of CA status was calculated routinely as a moving correlation coefficient between the slow waves of invasively measured intracranial pressure (ICP) and ABP signals by using ICM+ software (Cambridge, UK).

 

Results

The clinical assessment of non-invasive CA monitoring technology was carried out in Republic’s Vilnius University Hospital (Lithuania). The CA status was monitored for 42 severe comatose TBI patients in different pathophysiological states by comparing non-invasive vPRx with invasive PRx indexes. The obtained correlation between the indexes was r=0.71, standard deviation of difference between the indexes was SD=0.254. The total monitoring time of all patients was 56 hours.

 

Discussion

The limitations of the presented non-invasive CA monitoring technology are the sensitivity to patients’ movements and necessity to have required amplitude of IBV slow waves. In the first case, the movements of sedated comatose patients are rare, therefore they are identified and excluded from the results by software algorithms. The amplitude IBV slow waves is changing over time, from low spontaneous fluctuation to appearance of higher pathological “B waves”. In the most cases assessment was done by calculating CA indexes on spontaneous fluctuation of IBV with the amplitude of ICP slow waves ~1-3 mmHg being enough for reliable CA status estimation.

 

Conclusion

The prospective clinical study showed significant agreement between the non-invasively and invasively measured CA indexes. The proposed novel non-invasive CA real-time monitoring technology provides the similar diagnostic information as the invasive methods and can be used for long-term and continuous patients monitoring in ICU.

 

Acknowledgement: The research was funded by the grants MIP-087/2015 and MIP-118/2012 from the Research Council of Lithuania.

 

References

  1. Czosnyka M, Brady K, Reinhard M, et al. Monitoring of Cerebrovascular Autoregulation: Facts, Myths, and Missing Links. Neurocrit Care 2009; 10:373–386.
  2. Aries MJ, Czosnyka M, Budohoski KP, et al.Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med 2012;40(8):2456–2463.
  3. Preiksaitis A, Krakauskaite S, Petkus, et al. Association of Severe Traumatic Brain Injury Patient Outcomes With Duration of Cerebrovascular Autoregulation Impairment Events. Neurosurgery. 2016;79(1):75-82.

4.Petkus V, Preiksaitis A, Chomskis R, et al: Novel method and device for fully noninvasive cerebrovascular autoregulation monitoring. Electronics and Electrical Engineering 2014;20(8):24-29.

Non-invasive Cerebral Autoregulation Monitoring during Cardiac Surgery with Cardiopulmonary Bypass 2017-12-12T22:17:53+00:00

Synopsis

The prospective observational study was performed at the Hospital of Lithuanian University of Health Sciences in Kaunas (Lithuania). This study includes 65 patients without preoperative neurological disorders who were undergoing the elective coronary artery bypass grafting surgery. The study showed that duration of the longest cerebrovascular autoregulation impairment event during cardiopulmonary bypass surgery is associated with deteriorated mental abilities and risk of post-operative cognitive dysfunction. The calculated critical threshold of duration of the longest cerebrovascular autoregulation impairment events showing association with the deteriorated mental ability was 240 sec (2 = 4.11, p=0.04).

 

Target audience

The current clinical guidelines recommend that the mean arterial blood pressure (MAP) during cardiopulmonary bypass (CPB) should be kept 50-60 mmHg or higher [1]. But the individualized MAP identification is needed during CPB. Post-operative cognitive dysfunction (POCD) is a common complication after cardiac surgery with cardiopulmonary bypass. It occurs during the first post-operative week in approximately 33–83% of cases; and in 20–60% of cases, it may persist for several months after surgery [2-4].

 

Purpose

We hypothesized that patients undergoing CPB experience episodes of cerebrovascular autoregulation (CA) impairment episodes. This impairment is related to the deterioration of cognition (DC) and POCD. Goals of this study were to describe CA impairment episodes as well as to investigate the relationship between CA impairments and cognitive functions, and to discover the impact of MAP in patients undergoing CPB.

 

Methods

This prospective observational study was conducted in Kaunas Clinics, the Hospital of Lithuanian University of Health Sciences. The study included 65 patients without pre-operative neurological disorders who underwent elective coronary artery bypass graft surgery with CPB. All patients received standardized anaesthetics and CPB management.

The equipment used for patients’ monitoring during cardiac surgery:

– Non-invasive cerebrovascular autoregulation monitor,

– Draeger Infinity monitor (ECG, invasive MAP, SpO2, temperature),

– Non-invasive Invos Oxigenation monitor (rSO2).

Non-invasive CA monitor “Vittamed 505” is based on ultrasonic time-of-flight measurment principle, which can provide real-time information on intracranial blood volume (IBV) fluctuation in the small parenchymal vessels and arteriole swhich are responsible for cerebral blood flow autoregulation [5]. CA status was estimated continuously during surgery by calculating the time (t) dependence of non-invasively monitored Pressure Reactivity Index (vPRx(t)) as a moving correlation coefficient between slow waves of IBV(t) and MAP(t) within a 2 min time averaging window.

 

Results

CA monitoring data were collected from 65 patients. Six patients refused to participate in the follow-up and were excluded from the study. Post-hoc analysis was performed on the data of 59 patients. The oldest and the youngest patients were 83 and 51 years of age, respectively. The mean age of the study group was 66.7 years. There were 34 men and 25 women involved in the study (59% and 41%, respectively).

The mean duration of CPB was 87 min and the mean aortic cross–clamping time was 44 min. During surgery, all patients had episodes of impaired CA (when vPRx>0). The longest episode of CA impairment was 12.4 min; the shortest episode lasted 1 min.

After surgery, 22 patients (37%) showed DC and experienced POCD (group II). The other 37 patients (63%) did not display any evidence of cognitive deterioration (group I). No one in the study experienced major neurological complications (stroke, coma, stupor, etc.).

Results of prospective trial show that one of the main causes of post-operative deterioration of cognition and POCD is patient-specific cerebrovascular autoregulation impairment event which duration are:

–           above the critical threshold of 240 sec, when vPRx(t)>0

–           above the critical threshold of 150 sec, when vPRx(t)>0.2

–           above the critical threshold of 80 sec, when vPRx(t)>0.5

 

Discussion

Our results are consistent with Ono et al. (2012) and show no differences in the MAP between patients with and without POCD [6]. Nevertheless, individual patients’ analysis detected correlation between MAP and CA impairment. We observed vPRx> 0 in 15 patients (25%). In some of them, the lower CA limit was > 50 mmHg and the observed range was 61.4–69.5 mmHg.

 

Conclusion

This prospective clinical study of non-invasive CA monitoring in anesthetized patients during cardiac surgery with cardiopulmonary bypass showed that the duration of the single longest CA impairment event and the area under curve of CA index during these events are reliably associated with deterioration of mental abilities. One cause of impaired CA is cerebral perfusion pressure lower than the individual lower limit of CA.

 

References

1.Joshi B et al. AnesthAnalg 2012;114: 503–510.

  1. Gao L, Taha R, Gauvin D, Othmen LB, Wang Y, Blaise G: Postoperative cognitive dysfunction after cardiac surgery. Chest 2005, 128(5):3664-3670.
  2. Rundshagen I: Postoperative cognitive dysfunction. Dtsch Arztebl Int 2014, 111(8):119-125.
  3. Bruggemans EF: Cognitive dysfunction after cardiac surgery: Pathophysiological mechanisms and preventive strategies. Neth Heart J 2013, 21(2):70-73.
  4. Petkus V, Preiksaitis A, Chomskis R, et al:Novelmethod and device for fully non- invasive cerebrovascular autoregulation monitoring. Electronics and Electrical Engineering 2014; 20(8):24-29.
  5. Ono M, Brady K, Easley RB, et al: Duration and magnitude of blood pressure below cerebral autoregulation threshold during cardiopulmonary bypass is associated with major morbidity and operative mortality. J Thorac Cardiovasc Surg 2014; 147(1):483-489.

 

Association of severe traumatic brain injury patients’ outcomes with cerebrovascular autoregulation impairment events and optimal cerebral perfusion pressure. 2017-12-12T22:17:02+00:00

A. Preiksaitis1, V. Petkus2, S. Krakauskaite2, R. Chomskis2, S. Rocka3, S. Vosylius3, D. Rastenyte1, R. Ragauskas2

1Department of Neurology, Academy of Medicine, Lithuanian University of Health Sciences, Kaunas, Lithuania

2Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania

3Republic’s Vilnius University Hospital, Vilnius University, Clinics of Neurology and Neurosurgery, Vilnius, Lithuania

 

Objectives

To explore associations between dynamic of patient-specific cerebrovascular autoregulation (CA) of subjects who incured severe traumatic brain injury (TBI) and the management of “optimal cerebral perfusion pressure” (optCPP) with the outcome of severe TBI patients. Additional factors such as patients’ age, radiological data, blood sample tests‘ data were also included into outcome analysis.

 

Materials and Methods

CA monitoring of 41 severe TBI patients was performed by using ICM+ software (Cambridge, UK) in Republic’s Vilnius University Hospital. CA status is assessed by calculating pressure reactivity index (PRx (t)). Additionally, CPP(t) data were processed in order to obtain diagnostic information for making patient-specific management of the optCPP. The analysis of CA status dynamic was performed and the relationship between duration of the longest CA impairment (LCAI) event and patients’ outcomes was investigated.

 

Results

Durations of the single LCAI events associated with mortality were 30 min when PRx(t)>0.8; 40 min when PRx(t)>0.7 and 45 min when PRx(t)>0.6. The critical value of CPP(t) declination from optCPP per – 6 mmHg was associated with mortality. Multidimensional plots of GOS association with multiple factors showed that multiple correlation between GOS, ∆optCPP and age and between GOS, ∆optCPP and Helsinki CT (HCT) score were r = 0.67 and r=0.63 respectively; multiple correlations among GOS, LCAI duration and age, and among GOS, LCAI duration and HCT score were r = -0.73 and r=-0.54 respectively.

 

Conclusions

The analysis of GOS association with duration of LCAI events showed that the duration of the longest CA impairment event together with age and brain injury score are more significant factors impacting patients’ outcomes than the averaged pressure reactivity index PRx(t) values. Multidimensional analysis showed that better outcomes were obtained for younger patients (< 47 years) with lower HCT scores (HCT<6), for those whose LCAI event was shorter than 40 min when PRx(t) was above 0.7 within that CA impairment event and for patients whose CPP(t) was kept within the interval from optCPP to (optCPPopt +10 mmHg). OptCPP targeted therapy together with agressive electrolits and glucose correction might be a useful tool for improving CA and leading to more favourable outcomes for severe TBI patients.

 

Acknowledgement: This research has been funded by the grants MIP-118/2012  and MIP-087/2015 from the Research Council of Lithuania.

Non-invasive cerebral autoregulation monitoring during cardiac surgery with cardiopulmonary bypass. 2017-12-12T22:16:05+00:00

R. Zakelis1, B. Kumpaitiene2, S. Krakauskaite1, V. Petkus1, R. Chomskis1, M. Svagzdiene3, E. Sirvinskas3, R. Benetis3, R. Ragauskas1

1Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania

2Clinic of Cardiothoracic and Vascular Surgery, Kaunas Hospital of Lithuanian University of Health Sciences, Kaunas, Lithuania

3Institute of Cardiology, Lithuanian University of Health Sciences, Kaunas, Lithuania

 

Objectives

Post-operative cognitive dysfunction (POCD) follows after cardiac surgery with a cardiopulmonary bypass (CPB) what may be related to a temporal cerebral hypoperfusion and consequently to the impaired cerebrovascular autoregulation (CA). Objective is to validate prospectively the innovative non-invasive CA monitoring technology for patient-specific mean arterial blood pressure (MAP) management in order to prevent POCD.

 

Materials and Methods

The ongoing study has included 26 patients undergoing the CPB surgery. All patients were ASA III class, NYHA III class. Their average age was 63 years. The “Vittamed505” non-invasive CA monitor based on the intracranial blood volume (IBV) measurement within small arterial vessels and arterioles was used during surgery. The CA status was estimated continuously by calculating the pressure reactivity index vPRx(t) as a phase shift between the slow waves of MAP(t) and IBV(t) The neuropsychological tests were performed before and after CPB surgery for each patient in order to estimate changes of mental abilities and detect POCD.

 

Results

7 patients demonstrated deterioration of mental abilities after CPB surgery and one patient was diagnosed with POCD. These patients suffered from longer CA impairment (LCAI) events which lasted up to 250-300 sec. Deterioration of CA lasting up to a few minutes typically appears when MAP temporarily drops below the lowest individual patient specific MAP threshold. Calculated critical duration of LCAI events showing association with the deterioration of mental ability was 250 sec. Critical LCAI events duration showing the association with POCD was 410 sec. Correlation between the duration of LCAI and deterioration of mental ability was r = 0.705.

 

Conclusions

The preliminary study showed that the duration of LCAI event during CPB surgery is associated with deterioration of mental abilities and risk of POCD. The „Vittamed505” non-invasive CA monitor can be used for the patient-specific MAP management during cardiac CPB surgery in order to prevent cognitive dysfunctions. We intend to collect up to 56 patients’ data for evidence based validation of the presented method.

 

Acknowledgement: This research has been funded by the grants MIP-022/2014  and MIP-087/2015 from the Research Council of Lithuania.

 

Fig. 1. The association between the LCAI event duration and deterioration of mental abilities.

Non-invasive Cerebral Autoregulation Monitoring during Cardiac Surgery with Cardiopulmonary Bypass 2017-12-12T22:13:26+00:00

Synopsis

The current clinical guidelines recommend that the mean arterial blood pressure (MAP) during CPB should be kept 50-60 mmHg or higher [1]. But the individualized MAP identification is needed during CPB. The prospective observational study is commenced at the Hospital of Lithuanian University of Health Sciences in Kaunas. This ongoing study includes 26 patients without preoperative neurological disorders which are undergoing the elective coronary artery bypass grafting surgery.

The calculated critical threshold of duration of  longer cerebrovascular autoregulation impairment (LCAI) events showing association with the deteriorated mental ability was 250 sec (2 = 4.94, p=0.026). The critical threshold of LCAI events  duration showing the association with POCD was 410 sec (2 = 3.96, p=0.046). The correlation coefficient between the duration of LCAI and deterioration of mental ability was r = 0.705. The preliminary study showed that the duration of LCAI event during CPB surgery is associated with deteriorated mental abilities and risk of POCD.

 

Target audience

Post-operative cognitive dysfunction (POCD) is the most common clinical consequence of brain injury after cardiac surgery with a cardiopulmonary bypass (CPB) [1-2]. POCD after cardiac surgery occurs in up to 40–60 % of cases in the early postoperative period and their incidence still remains high after 6 weeks (~ 30 %) and 1 year (~ 25 %) [1].

 

Purpose

Our hypothesis is that POCD can be related to a temporal cerebral hypo-perfusion and consequently to the patient specific impairment of cerebrovascular autoregulation (CA).

 

Methods

The prospective observational study is commenced at the Hospital of Lithuanian University of Health Sciences in Kaunas. This ongoing study includes patients without preoperative neurological disorders which are

undergoing the elective coronary artery bypass grafting surgery.

The equipment used for patients’ monitoring during cardiac surgery:

– Non-invasive “Vittamed” cerebrovascular autoregulation (CA) monitor,

– Draeger Infinity monitor (ECG, invasive MAP, SpO2, temperature),

– Non-invasive Invos Oxigenation monitor (rSO2).

The “Vittamed” non-invasive CA monitor [3] is based on ultrasonic time-of-flight measurment principle and is capable to provide real-time information on the intracranial blood volume (IBV) pulsation in the brain vessels responsible for cerebral blood flow autoregulation – in small arterial vessels and arterioles (Fig. 1). The CA status is estimated continuously during CPB by calculating the pressure reactivity index vPRx(t) as a moving correlation coefficient between the slow waves of MAP(t) and IBV(t) [3].

 

Results

The preliminary clinical study of CA monitoring was performed on 26 cardiac surgery patients. All patients were ASA III class, NYHA III class; their average age was 63 years. For one patient POCD was detected (Zcombined = −6.67 < −2). Some single tests also showed deteriorated mental abilities for other 7 patients (RCI < −1.645). These patients were suffering from LCAI events when vPRx(t)>0. Such events lasted for more than 250-300 sec. It was shown that the deterioration of CA lasting up to a few minutes typically appears when MAP temporarily drops below the lowest individual patient specific MAP threshold (50…60 mmHg) and at the beginning/finishing moments of CPB.

The calculated critical threshold of duration of LCAI events showing association with the deteriorated mental ability was 250 sec (2 = 4.94, p=0.026). The critical threshold of LCAI events  duration showing the association with POCD was 410 sec (2 = 3.96, p=0.046). The correlation coefficient between the duration of LCAI and deterioration of mental ability was r = 0.705.

 

Discussion

The current clinical guidelines recommend that the mean arterial blood pressure (MAP) during CPB should be kept 50-60 mmHg or higher [2]. But the individualized MAP identification is needed during CPB. We propose to use the innovative ultrasonic real–time CA monitoring technology [3] for identification of the individual patient-specific MAP values during CPB in order to prevent brain injury and POCD.

 

Conclusion

The preliminary study showed that the duration of LCAI event during CPB surgery is associated with deteriorated mental abilities and risk of POCD. The „Vittamed505” non-invasive CA monitor can be used for the patient-specific MAP management during cardiac CPB surgery in order to prevent cognitive dysfunctions. We intend to collect up to 56 patients’ data for evidence based validation of the presented method.

 

References

1.Joshi B et al. Anesth Analg 2012;114: 503–510.

  1. Sun X et al. J Am Coll Cardiol 2012; 60: 791-797.
  2. Ragauskas A. et al. European Patent No. 2111787 B1, 2011, US Patent US7998075 B2, 2009.
  3. Lewis MS et al. Archives of Clinical Neuropsychology. 2006; 21:421–427.
Prospective comparative clinical study of non-invasive cerebrovascular autoregulation monitor. 2017-12-12T22:12:16+00:00

1Ragauskas A, 1Petkus V, 1Krakauskaite S, 1Chomskis R,  2Preiksaitis A.

1Health Telematics Science Institute, Kaunas University of Technology, Lithuania.

2 Republic’s Vilnius University Hospital, Vilnius University, Clinics of Neurology and Neurosurgery, Lithuania. email: vytautas.petkus@ktu.lt

 

Background. The results are presented of prospective comparative study of simultaneous fully non-invasive (without ABP(t) line) and invasive cerebrovascular autoregulation (CA) monitoring on severe TBI patients. The aim of the study was to validate the non-invasive CA monitoring technology [1,2,3] and to explore its suitability for identification of CA and optimal cerebral perfusion pressure (optCPP).

 

Methods. The non-invasive CA monitor is based on the ultrasonic transintracranial “time-of-flight” (TOF) measurement of intracranial blood volume (IBV) pulsations and waves within the brain parenchyma [2]. The monitor provides the possibilities of non-invasive CA estimation with or without using the external arterial blood pressure (ABP(t)) monitoring line. CA status is estimated by the slow IBV waves extracted from the non-invasively measured TOF(t) and by the reference ABP(t) signal or by the non-invasively identified reference signal which replaces ABP(t) signal. The phase difference between the IBV(t) slow waves and the reference slow waves is used as the CA estimation index vPRx. The special envelope signal extracted from the non-invasively measured IBV pulse waves is proposed as a reference signal which is used instead of ABP(t) reference signals to calculate the CA estimation index vPRx [3].

The clinical assessment of non-invasive CA monitoring technology was carried out in Republic’s Vilnius University Hospital (Lithuania). The CA status was monitored for 28 severe TBI patients (22 males, 6 females, aged 18-66) simultaneously invasively by using ICM+ software tool (Cambridge, UK) and non-invasively by Vittamed 505 (Vittamed, Lithuania) monitor.

 

Results. The comparative invasive versus non-invasive CA monitoring study of 28 TBI patients showed that the correlation between the invasively measured PRx(t) data and the non-invasively measured vPRx(t) data was r=0.74 (with ABP measurement line) and r=0.72 (without ABP line). The analysis of the reference signals extracted from the envelope of the non-invasively measured IBV(t) pulse waves showed the agreement with the ABP(t) reference slow wave signals (r=0.68).

 

Discussion. The results of the ongoing clinical study demonstrated significant agreement between the invasive and non-invasive CA monitoring technologies under comparison. The non-invasive CA monitoring technology with or without the external ABP line provides similar diagnostic information on CA status thus showing the possibility to implement CA measurements in the cases when the invasive CA monitoring or the ABP line are not available.

 

Conclusion. The proposed non-invasive CA real-time monitoring technology provides the same diagnostic information as the invasive PRx(t) monitoring technology. The estimation of the CA status from the non-invasively recorded intracranial volume waves only exclude the ABP line’s errors and artefacts from the CA monitoring results.

 

Key references.

  1. Petkus V et al. In: Proc. Computer-Based Medical Systems. 2014; 427-30.
  2. Ragauskas A et al. European Patent No. 2111787 B1, 2011, US Patent 20090270734, 2009.
  3. Ragauskas A et al. Med Eng Phys. 2003; 25:667-78.

 

Acknowledgement: This research has been funded by the grant MIP-118/2012 from the Research Council of Lithuania and the Swiss – Lithuanian project No.CH-3-SMM-01/06.

 

 

Association of the outcome of traumatic brain injury patients with cerebrovascular autoregulation impairment events. 1Ragauskas A, 1Petkus V, 1Krakauskaite S, 1Chomskis R, 2Preiksaitis A, 2Rocka S.

1Health Telematics Science Institute, Kaunas University of Technology, Lithuania.

2 Republic’s Vilnius University Hospital, Vilnius University, Clinics of Neurology and Neurosurgery, Lithuania. email: vytautas.petkus@ktu.lt

 

Background. The aim of the prospective study was to explore associations of TBI patient specific cerebrovascular autoregulation (CA) dynamic and “optimal cerebral perfusion pressure” (optCPP) management [1,2] with the outcome of severe TBI patients. Information on patients’ age and grade of diffuse axonal injury (DAI) was also included into the analysis.

Methods. CA monitoring of 33 severe TBI patients was performed by using ICM+ software (Cambridge, UK) in Republic’s Vilnius University Hospital. CA status estimating pressure reactivity index (PRx (t)) and CPP(t) data were processed in order to obtain diagnostic information for making patient-specific treatment decisions by using management of the optCPP [1]. The analysis of CA status dynamic was performed and the relationship between duration of the longest CA impairment (LCAI) event and patients’ outcome was investigated.

 

Results. Association of Glasgow outcome scale (GOS) with the averaged value of PRx(t) showed negative correlation (r = – 0.40). The averaged value {PRx} > 0.24 was associated with mortality. The correlation  between GOS and the difference optCPP = CPP – optCPP was r = 0.484. The critical value of CPP(t) declination from optCPP per – 6 mmHg was associated with mortality. Multiple correlation between GOS, optCPP and age was r = – 0.79. Durations of the longest single critical CA impairment events responsible for mortality were  25 min when PRx(t)>0.8; 40 min when PRx(t)>0.7 and 80 min when PRx(t)>0.6. Multiple correlations  between GOS, LCAI and age and between GOS, LCAI and DAI grade were r = – 0.73 and r = – 0.59, respectively.

 

Discussion. The preliminary prospective study on TBI patients shows that unfavorable outcome of TBI patients is more significantly associated with duration of a single longest CA impairment episode but not with the time average of all CA impairments including relatively short secondary insults. This finding contradicts the present integrative approach of association between CA impairments and unfavorable outcomes of severe TBI patients. The pharmaceutical patient-specific management (adrenominetic, nitrite, thiopental, hypertonic saline, etc.), respiratory gas adjustment or decompressive craniectomy are available tools for maintaining CPP close to optCPP. OptCPP-targeted therapy allows eliminating too long single CA impairments and leads to a more favourable outcome of severe TBI patients.

 

Conclusion. The analysis of GOS association with duration of LCAI events showed that the outcomes of severe TBI patients are significantly associated with duration of the single longest CA impairment event, age and DAI grade. Multidimensional representation of GOS plots showed that better outcomes were obtained for younger patients (< 47 years) with lower DAI grades (1 or 2), for those whose LCAI event was shorter than 40 min when PRx(t) was above  0.7 within that CA impairment event and for patients whose CPP(t) was kept within the interval from optCPP to  (optCPPopt +10 mmHg).

 

Key references.

  1. Steiner LA et al. Crit Care Med. 2002; 30(4): 733–8.
  2. Le Roux et al. Intensive Care Med. 2014;40(9):1189-209.

Acknowledgement: This research has been funded by the grant MIP-118/2012 from the Research Council of Lithuania and the Swiss – Lithuanian grant No.CH-3-SMM-01/06.

Association of the outcome of the traumatic brain injury patients with cerebrovascular autoregulation, cerebral perfusion pressure, age and injury grades. 2017-12-12T22:11:24+00:00

Solventa Krakauskaite1, Vytautas Petkus1, Romanas Chomskis1, Aidanas Preiksaitis2, Arminas Ragauskas1. 1Kaunas University of Technology, Health Telematics Science Institute, Kaunas, Lithuania. 2Vilnius University, Faculty of Medicine, Clinics of Neurology and Neurosugery, Centre of Neuroangiosurgery, Vilnius, Lithuania. Contact information: Studentu St. 48-446, LT-51367, Kaunas, Lithuania, solventa@mail.com, vytautas.petkus@ktu.lt. Key words: cerebrovascular autoregulation monitoring; optimal cerebral perfusion pressure monitoring; traumatic brain injury.

 

Introduction

The main factors influencing treatment of traumatic brain injury (TBI) patients to leading for a better outcome are cerebral perfusion pressure (CPP), cerebrovascular autoregulation (CA), age and brain injury severity. The impairment of CA has a strong impact on the outcome of the TBI patients, therefore, it is essential to know the real-time status of CA [1, 2]. The consensus has already been achieved that the cerebral blood flow (CBF) autoregulatory state of the TBI patients has to be monitored and the individualized treatment strategy should be re-valuated regularly over the time course of the CBF autoregulation status [3, 4].

 

Background and Objective

The aim of the prospective study was to explore the influence of cerebrovascular autoregulation and “optimal cerebral perfusion pressure (optCPP)” managing conditions on the traumatic brain injury patients’ outcome including additional information about the patients’ age and grade of diffuse axonal injury (DAI).

 

Material and Methods

The prospective study of CA status monitoring and the data analysis of 36 TBI patients was performed by using ICM+ software (Cambridge, UK). The CA status estimating pressure reactivity indexes (PRx) and CPP data were processed in order to obtain information on the patient-specific treatment conditions by calculating the optCPP. Additional information about the age and TBI rate was included in calculating the association of the outcome of TBI patients with CA status and CPP monitoring data.

 

Results

  • The association of Glasgow outcome scale (GOS) and PRx showed negative correlation: r=-0.448 at hospital discharge and r=-0.402 after 6 months.
  • The correlation coefficients between GOS and time in percentage of CA impairment were r=-0.442 at hospital discharge and r=-0.433 after 6 months.
  • The correlation coefficients between GOS and difference CPP-“optimal CPP” were r=0.549 at hospital discharge and r=0.484 after 6 months.
  • The correlation between the GOS and age was r=-0.585 and between GOS and DAI grade was r=-0.518. The poorer outcome is predicted for elderly TBI patients (age>47 years) and patients having DAI grade=3.

 

Conclusions

The dependences of the GOS on CPP, CA impairment conditions, age and diffuse axonal injury grade showed that outcomes of TBI patients are associated with patient-specific CPP management and better outcomes were obtained for younger patients, for patients having lower DAI grade and for the patients whose CPP were kept within the range from the optCPP to the optCPP+10 mmHg.

 

References

[1]        Sviri GE, Newell DW. Cerebral Autoregulation Following Traumatic Brain Injury. The Open Neurosurgery Journal 2010;3:6-9.

[2]        Czosnyka M, Smielewski P, Lavinio A, Czosnyka Z, Pickard JD. A synopsis of brain pressures: which? when? Are they all useful? Neurol Res 2007;29(7):672–9. http://dx.doi.org/10.1179/016164107X240053.

[3]        Andrews PJD, Citerio G, Longhi L, Polderman K, Sahuquillo J, Vajkoczy P. NICEM consensus on neurological monitoring in acute neurological disease. Intensive Care Med 2008; 34:1362-70. http://dx.doi.org/10.1007/s00134-008-1103-y.

[4]        Brain Trauma Foundation, American Association of Neurological Surgeons, Congress of Neurological Surgeons, Joint Section on Neurotrauma and Critical Care, AANS/CNS. Guidelines for the management of severe traumatic brain injury. IX. Cerebral perfusion thresholds. J Neurotrauma 2007;24(suppl 1):S 59–S64.

Non-invasive ICP absolute value measurement technology. 2017-12-12T22:10:38+00:00

Solventa Krakauskaite1, Rolandas Zakelis1, Vytautas Petkus1, Laimonas Bartusis1, Romanas Chomskis1, Aidanas Preiksaitis2, Arminas Ragauskas1. 1Kaunas University of Technology, Telematics Science Centre, Kaunas, Lithuania. 2Vilnius University, Faculty of Medicine, Clinics of Neurology and Neurosugery, Centre of Neuroangiosurgery, Vilnius, Lithuania. Contact information: Studentu St. 48-446, LT-51367, Kaunas, Lithuania, solventa@mail.com, telematics@ktu.lt. Key words: non-invasive ICP absolute value method; two depth transcranial Doppler meter; Bland & Altman, regression and ROC analysis.

 

Introduction.

ABP and ICP are both fundamental physiological parameters with the same importance. It is possible to measure ABP non-invasively from 1904 (Joseph Erlanger, Nobel Prize in 1944). Intracranial arteries are the natural pressure sensors. The ophthalmic artery (OA) is an unique vessel with almost the same anatomy of intracranial and extracranial segments. Because of that we proposed to use the OA as a natural ‘scales’ for aICP measurement and to use a two depth transcranial Doppler meter (TCD) as a balance indicator of such ‘scales’. This is ‘re-invention’ of non – invasive ABP measurement method for aICP value measurement application.

Our devices are currently used by clinical centers in Lithuania, Sweden, Finland, Norway, Switzerland and also by NASA, NSBRI and BMC in the US and by German Aerospace Research Institute.

 

Objectives.

  1. To validate accuracy, precision, sensitivity and specificity of proposed innovative non-invasive absolute intracranial pressure measurement method which does not need a patient’s specific calibration by multicenter comparative clinical studies on wide groups of neurological and Traumatic Brain Injury (TBI) patients:
  • Turku (Finland) and Aarau (Switzerland) hospitals: TBI and SAH patients, invasive ‘gold standard’ ventricular pressure sensors, prospective study.
  • Republic Vilnius University Hospital: TBI patients, ventricular ‘gold standard’ invasive ICP sensors, prospective study.
  • Lithuanian University of Health Sciences and Baylor College of Medicine: prospective neurological patient Phase III study: non – invasive ICP comparing with ‘gold standard’ CSF pressure measured via lumbar puncture.

 

Methods.

Prospective randomized comparative clinical studies of simultaneous non-invasive aICP and ‘gold standard’ invasive ICP measurements. Data collected from 152 patients from clinical centers in Lithuania (Vilnius, Kaunas), Switzerland (Aarau), Finland (Turku).

 

Results.

Bland & Altman plot of 219 paired non-invasive and invasive ICP data points showed that mean systematic error (accuracy) of non-invasive aICP value measurement was equal to 0.10 mmHg (CL = 97.7%) and standard deviation of the random error (precision) SD = 2.56 mmHg (CL = 97.7%).

ROC analysis showed the area under ROC curve AUC = 0.913 (CL = 95%) with sensitivity 73.97 % (CL = 95%) and specificity 91.89 % (CL = 0.95) when ΔPe = 4.0 mmHg. In the case when Δ Pe = 2.0 mmHg, AUC = 0.983 (CL = 95%) with sensitivity 87.67 % (CL = 95%) and specificity 97.30 % (CL = 95%).

 

Conclusions.

  1. ROC analysis confirms high sensitivity (87.67%), specificity (97.30%) and area under ROC curve (0.983) of non-invasive ICP measurement method when sampling step is Δ Pe = 2.0 mmHg of externally applied pressure Pe(t).
  2. Multi-center comparative clinical studies showed negligible systematic error and low enough random errors’ SD of innovative non-invasive ICP measurement method in a wide range of ICP values from 4.7 mmHg up to 30 mmHg.

 

Clinical studies and technology development were funded by EU FP7 projects:

  • FP7 Center TBI – Collaborative European NeuroTrauma Effectiveness Research in TBI.
  • Brainsafe II – Development of a Novel Autonomous Non-Invasive Absolute Intracranial Pressure Measurement Device Based on Ultrasound Doppler Technology.
  • TBICare – Evidence based Diagnostic and Treatment Planning Solution for Traumatic Brain Injuries.
  • BrainCare – Scientific research and development of innovative evidence based non-invasive brain diagnostic and monitoring solutions for neurological and TBI patients.

US projects:

  • Randomized prospective non-invasive ICP measurement study of patients with idiopathic hypertension syndrome. Study partially supported by NASA.

•           NSBRI (NASA) – Research and Technology Development to Support Crew Health and Performance in Space Exploration Missions

Accuracy, precision, sensitivity and speci city of non-invasive absolute intracranial pressure value measurement method 2017-12-12T22:09:46+00:00

A. Ragauskas1, L. Bartusis1, R. Zakelis1, G. Daubaris1 S. Krakauskaite1, V. Matijosaitis2, K. Petrikonis2, D. Rastenyte2

1Kaunas University of Technology / Health Telematics Science Institute, Kaunas, Lithuania
2Lithuanian University of Health Sciences / Kaunas Clinics / Department of Neurology, Kaunas, Lithuania

 

Background: Accuracy, precision, sensitivity and speci city of an innovative absolute intracranial pressure (aICP) measure- ment method which does not need a patient speci c calibration has been validated by multicenter comparative clinical studies on wide groups of neurological and Traumatic Brain Injury patients. Methods: Prospective randomized comparative clinical studies (including blinded studies) of simultaneous non-invasive aICP and “gold standard” invasive ICP measurements have been conducted. Data were collected from 127 patients (188 independent paired data points). Bland and Altman and Receiver Operating Charac- teristic (ROC) analyses have been performed. Results: Accuracy of non-invasive aICP meter (expressed by the mean systematic er- ror ∆) is ∆ = 0.04 mmHg, CL = 0.97. Precision of aICP meter (ex- pressed by SD of random error) is SD = 2.47 mmHg (CL = 0.97). ROC analysis showed an area under ROC curve, AUC = 0.94 with sensitivity of 73.7 % (CL = 0.95) and speci city of 94.7 % (CL = 0.95). Conclusions: Negligible systematic error and low enough random errors’ SD of non-invasive aICP measurement method were observed in a wide range of aICP values from 5 mmHg to 30 mmHg. Clinically validated method shows practically applicable accuracy, precision, sensitivity and speci city. e statistically sig- ni cant clinical validation results support hypothesis on no need of calibration to the individual patient or healthy person of created aICP measurement method.

Novel technology of non-invasive cerebrovascular autoregulation monitoring. 2017-12-12T22:08:39+00:00

Vytautas Petkus, Solventa Krakauskaite, Romanas Chomskis, Laimonas Bartusis, Arminas Ragauskas. Telematics Science Centre Kaunas University of Technology Kaunas, Lithuania telematics@ktu.lt

Aidanas Preiksaitis, Saulius Rocka. Clinics of Neurology and Neurosurgery, Centre of Neuroangiosurgery, Vilnius University Faculty of Medicine Vilnius, Lithuania

 

Abstract—A novel technology for non – invasive cerebrovascular autoregulation (CA) status monitoring is presented. This fully non-invasive CA monitor is based on ultrasonic time-of-flight (TOF) measurement of cerebral blood volume pulsations within the brain parenchyma, processing of volumetric waves, and calculation of CA estimation indexes without using any additional arterial blood pressure (ABP) measurements. The CA status is estimated by extracting informative and reference slow waves from non-invasively measured TOF signals and by calculating Pearson’s correlation coefficient between these waves as a CA index. The analysis of the signal extracted from the envelope of non- invasively measured pulse waves showed good agreement between this signal and ABP waves (r=0.68). Consequently, it shows that this signal might be used instead of ABP waves as a reference signal for calculation of the CA estimation indexes. Comparative invasive versus non-invasive CA monitoring study of 11 traumatic brain injury patients showed that correlation between invasively measured CA index and fully non-invasively measured CA index (no arterial line) was r=0.75. The proposed innovative CA real-time monitoring method gives us new possibilities to perform estimation of the CA status from intracranial waves only as well as to exclude the ABP line’s errors and artifacts from the measurement results.

Innovative computerized non-invasive intracranial pressure measurement technology and its clinical validation 2017-12-12T22:08:15+00:00

Solventa Krakauskaite, Vytautas Petkus, Rolandas Zakelis, Laimonas Bartusis, Romanas Chomskis, Arminas Ragauskas. Health Telematics Science Institute, Kaunas University of Technology, Kaunas, Lithuania. telematics@ktu.lt

 

Abstract — An innovative non-invasive absolute intracranial pressure (aICP) measurement method has been validated by multicenter comparative clinical studies. The method is based on two-depth transcranial Doppler technology and employs intracranial and extracranial segments of the ophthalmic artery as a pressure sensor. The ophthalmic artery is used as a natural pair of scales which compares aICP with controlled pressure aPe which is externally applied to the orbit. In the case of scales balance, aICP=aPe. A two-depth transcranial Doppler device is used as a pressure balance indicator. The proposed method is the only non-invasive aICP measurement method which does not need patient-specific calibration.

 

 

Accuracy, precision, sensitivity and specificity of non-invasive ICP absolute value measurements. 2017-12-12T22:06:40+00:00

Solventa Krakauskaite1, Rolandas Zakelis1, Vytautas Petkus1, Laimonas Bartusis1, Romanas Chomskis1, Aidanas Preiksaitis2, Arminas Ragauskas1. 1Kaunas University of Technology, Telematics Science Centre, Kaunas, Lithuania. 2Vilnius University, Faculty of Medicine, Clinics of Neurology and Neurosugery, Centre of Neuroangiosurgery, Vilnius, Lithuania. Contact information: Studentu St. 48-446, LT-51367, Kaunas, Lithuania, solventa@mail.com, telematics@ktu.lt.

Key words: non-invasive ICP absolute value method; two depth transcranial Doppler meter; Bland & Altman, regression and ROC analysis.

 

Introduction.

Intracranial arteries are the natural pressure sensors. The ophthalmic artery (OA) is an unique vessel with almost the same anatomy of intracranial and extracranial segments. Because of that we proposed to use the OA as a natural „scales“ for aICP measurement and to use a two depth transcranial Doppler meter (TCD) as a balance indicator of such ”scales“. This is „re-invention“ of non – invasive ABP measurement method for aICP value measurement application.

 

Objectives.

  1. To validate accuracy, precision, sensitivity and specificity of proposed non-invasive aICP measurement method by multicenter comparative clinical studies (Bland & Altman, regression and ROC analysis) on wide groups of neurological and ICU patients:
  • Turku Hospital: TBI patients, invasive “gold standard” ventricular or parenchymal pressure sensors prospective study.
  • Republic Vilnius University Hospital: TBI patients, ventricular “gold standard” invasive ICP sensors prospective study.
  • Lithuanian Life Science University: prospective neurological patient Phase III study: non – invasive ICP comparing with “gold standard” CSF pressure measured via lumbar puncture.
  • Umea Hospital: dynamic infusion tests on elderly neurological patient group (age 65-85) prospective double blinded study.
  1. To validate linearity study (HUT/HDT, regression analysis) at Kaunas University of Technology.

 

Methods.

Prospective randomized comparative clinical studies of simultaneous non-invasive aICP and “gold standard” invasive ICP measurements. Data collected from 110 patients from clinical centers in Lithuania (Vilnius, Kaunas), Sweden (Umeå), Finland (Turku).

Healthy volunteers’ study was performed with 217 snapshots by aICP non-invasive measurements in 6 body positions.

 

Results.

Bland & Altman plot of 171 paired non-invasive and invasive ICP data points showed that mean systematic error (accuracy) of non-invasive aICP value measurement was equal to 0.03 mmHg and standard deviation of the random error (precision) SD = 2.65 mmHg (CL = 0.965) or SD = 2.2 mmHg (CL = 0.95).

Healthy volunteers’ study confirms linearity (R=0.995) of non-invasive aICP value measurement method in the clinically important aICP range [6.3 – 37.8 mmHg] which is below and above of critical ICP thresholds 14.7 mmHg (neurology) and 20.0 mmHg (neurosurgical intensive care).

 

Conclusions.

  1. ROC analysis confirms high sensitivity (88%), specificity (93%) and area under ROC curve (0.96) of non-invasive ICP measurement method.
  2. Negligible mean systematic error (0.03 mmHg) is a statistically significant evidence of two – depth TCD based non-invasive aICP value measurement method and shows that is the only which does not need a patient specific calibration.

 

Clinical studies and technology development were funded by EU FP7 projects:

  • Brainsafe II – Development of a Novel Autonomous Non-Invasive Absolute Intracranial Pressure Measurement Device Based on Ultrasound Doppler Technology.
  • TBICare – Evidence based Diagnostic and Treatment Planning Solution for Traumatic Brain Injuries.
  • BrainCare – Scientific research and development of innovative evidence based non-invasive brain diagnostic and monitoring solutions for neurological and TBI patients.

US projects:

  • Randomized prospective non-invasive ICP measurement study of patients with idiopathic hypertension syndrome. Study partially supported by NASA.
  • NSBRI (NASA) – Research and Technology Development to Support Crew Health and Performance in Space Exploration Missions.
Noninvasive monitoring of cerebrovascular autoregulation response to resistance exercises. 2017-12-12T18:57:34+00:00

Medicina (Kaunas). 2012;48(1):39-47. Epub 2012 Feb 22.

Petkus V1, Kalasauskienė A, Ragauskas A, Chomskis R, Krutulytė G, Kalasauskas L.

Abstract 

BACKGROUND AND OBJECTIVE. A novel noninvasive monitor is presented by demonstrating its capabilities to perform the real-time estimation of dynamics in cerebrovascular autoregulation in athletes during their training. The aim was to explore the characteristics of human cerebrovascular autoregulation by performing the monitoring of cerebrovascular autoregulation responses to resistance exercises in healthy volunteer athletes. MATERIAL AND METHODS. Cerebrovascular autoregulation status was monitored in 20 amateur and 20 elite male athletes (weightlifters and bodybuilders) in the supine position at rest during and after the resistance exercises by using a novel noninvasive monitor “Vittamed.” Blood pressure and heart rate were also measured noninvasively. During the exercises, the athletes lifted 50 kg and 80% of 1RM (repetition maximum) weights in a dynamic and static manner in separate tests. RESULTS. The cerebrovascular autoregulation reactivity index showed a temporal improvement in the cerebrovascular autoregulation status for almost all sportsmen after the exercises. No disturbances of cerebrovascular autoregulation response occurred in the weightlifters and amateur athletes after the static and dynamic exercises. However, an unstable status of cerebrovascular autoregulation was observed for the elite bodybuilders during the interval of 400 to 600 s after the exercises. CONCLUSIONS. The data of this study demonstrated significant differences in cerebrovascular autoregulation response to the resistance exercises between the elite bodybuilders and other subjects (amateurs and weightlifters) – a temporarily unstable status of cerebrovascular autoregulation was observed in the group of elite bodybuilders. This study also demonstrated the applicability of the noninvasive device for exploring the physiology of cerebrovascular autoregulation mechanism in elite athletes and healthy volunteers.

Improved diagnostic value of a TCD-based non-invasive ICP measurement method compared with the sonographic ONSD method for detecting elevated intracranial pressure. 2017-12-12T18:56:37+00:00

Neurol Res. 2014 Jul;36(7):607-14. doi: 10.1179/1743132813Y.0000000308. Epub 2014 Jan 12.

Ragauskas A, Bartusis L, Piper I, Zakelis R, Matijosaitis V, Petrikonis K, Rastenyte D.

Abstract

OBJECTIVES:

To compare the diagnostic reliability of optic nerve sheath diameter (ONSD) ultrasonography with a transcranial Doppler (TCD)-based absolute intracranial pressure (ICP) value measurement method for detection of elevated ICP in neurological patients. The ONSD method has been only tested previously on neurosurgical patients.

METHODS:

A prospective clinical study of a non-invasive ICP estimation method based on ONSD correlation with ICP and an absolute ICP value measurement method based on a two-depth TCD technology has recruited 108 neurological patients. Ninety-two of these patients have been enrolled in the final analysis of the diagnostic reliability of ONSD ultrasonography and 85 patients using the absolute ICP value measurement method. All non-invasive ICP measurements were compared with ‘Gold Standard’ invasive cerebrospinal fluid (CSF) pressure measurements obtained by lumbar puncture. Receiver-operating characteristic (ROC) analysis has been used to investigate the diagnostic value of these two methods.

RESULTS:

The diagnostic sensitivity, specificity, and the area under the ROC curve (AUC) of the ONSD method for detecting elevated intracranial pressure (ICP >14·7 mmHg) were calculated using a cutoff point of ONSD at 5·0 mm and found to be 37·0%, 58·5%, and 0·57, respectively. The diagnostic sensitivity, specificity, and AUC for the non-invasive absolute ICP measurement method were calculated at the same ICP cutoff point of 14·7 mmHg and were determined to be 68·0%, 84·3%, and 0·87, respectively.

CONCLUSIONS:

The non-invasive ICP measurement method based on two-depth TCD technology has a better diagnostic reliability on neurological patients than the ONSD method when expressed by the sensitivity and specificity for detecting elevated ICP >14·7 mmHg.

 

KEYWORDS:

Absolute intracranial pressure; Diagnostic reliability; Doppler technology; Non-invasive measurement; Optic nerve sheath diameter

The difference in translaminar pressure gradient and neuroretinal rim area in glaucoma and healthy subjects. 2017-12-12T18:55:23+00:00

J Ophthalmol. 2014;2014:937360. doi: 10.1155/2014/937360. Epub 2014 Apr 30.

Siaudvytyte L1, Januleviciene I1, Ragauskas A2, Bartusis L3, Meiliuniene I1, Siesky B4, Harris A5.

Abstract

Purpose. To assess differences in translaminar pressure gradient (TPG) and neuroretinal rim area (NRA) in patients with normal tension glaucoma (NTG), high tension glaucoma (HTG), and healthy controls. Methods. 27 patients with NTG, HTG, and healthy controls were included in the prospective pilot study (each group consisted of 9 patients). Intraocular pressure (IOP), intracranial pressure (ICP), and confocal laser scanning tomography were assessed. TPG was calculated as the difference of IOP minus ICP. ICP was measured using noninvasive two-depth transcranial Doppler device. The level of significance P < 0.05 was considered significant. Results. NTG patients had significantly lower IOP (13.7(1.6) mmHg), NRA (0.97(0.36) mm(2)), comparing with HTG and healthy subjects, P < 0.05. ICP was lower in NTG (7.4(2.7) mmHg), compared with HTG (8.9(1.9) mmHg) and healthy subjects (10.5(3.0) mmHg); however, the difference between groups was not statistically significant (P > 0.05). The difference between TPG for healthy (5.4(7.7) mmHg) and glaucomatous eyes (NTG 6.3(3.1) mmHg, HTG 15.7(7.7) mmHg) was statistically significant (P < 0.001). Higher TPG was correlated with decreased NRA (r = -0.83; P = 0.01) in the NTG group. Conclusion. Translaminar pressure gradient was higher in glaucoma patients. Reduction of NRA was related to higher TPG in NTG patients. Further prospective studies are warranted to investigate the involvement of TPG in glaucoma management.

Update in intracranial pressure evaluation methods and translaminar pressure gradient role in glaucoma. 2017-12-12T18:54:12+00:00

ActaOphthalmol. 2015 Feb;93(1):9-15. doi: 10.1111/aos.12502. Epub 2014 Jul 18.

Siaudvytyte L1, Januleviciene I, Ragauskas A, Bartusis L, Siesky B, Harris A.

Abstract

Glaucoma is one of the leading causes of blindness worldwide. Historically, it has been considered an ocular disease primary caused by pathological intraocular pressure (IOP). Recently, researchers have emphasized intracranial pressure (ICP), as translaminar counter pressure against IOP may play a role in glaucoma development and progression. It remains controversial what is the best way to measure ICP in glaucoma. Currently, the ‘gold standard’ for ICP measurement is invasive measurement of the pressure in the cerebrospinal fluid via lumbar puncture or via implantation of the pressure sensor into the brains ventricle. However, the direct measurements of ICP are not without risk due to its invasiveness and potential risk of intracranial haemorrhage and infection. Therefore, invasive ICP measurements are prohibitive due to safety needs, especially in glaucoma patients. Several approaches have been proposed to estimate ICP non-invasively, including transcranial Doppler ultrasonography, tympanic membrane displacement, ophthalmodynamometry, measurement of optic nerve sheath diameter and two-depth transcranial Doppler technology. Special emphasis is put on the two-depth transcranial Doppler technology, which uses an ophthalmic artery as a natural ICP sensor. It is the only method which accurately and precisely measures absolute ICP values and may provide valuable information in glaucoma.

© 2014 The Authors ActaOphthalmologica published by John Wiley & Sons Ltd on behalf of ActaOphthalmologicaScandinavica Foundation.

 

KEYWORDS:

glaucoma; intracranial pressure; non-invasive two-depth transcranial Doppler device; translaminar pressure gradient

Collaborative European NeuroTrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI): a prospective longitudinal observational study. 2017-12-12T18:52:59+00:00

Neurosurgery. 2015 Jan;76(1):67-80. doi: 10.1227/NEU.0000000000000575.

Maas AI1, Menon DK, Steyerberg EW, Citerio G, Lecky F, Manley GT, Hill S, Legrand V, Sorgner A; CENTER-TBI Participants and Investigators.

Collaborators (216)

Andelic N, Andreassen L, Andrews P, Audibert G, Audny A, Azouv P, Barzó P, Beer R, Bellander BM, Belli A, Benali H, Berardino M, Beretta L, Brazinová A, Binder H, Brehar F, Buki A, Bullinger M, Cakmak E, Callebaut I, Cameron P, Lozano GC, Carpenter KL, Chieregato A, Citerio G, Coburn M, Coles JP, Cooper J, Cnossen M, Curry N, Czeiter E, Czosnyka M, Dahyot-Fitzelier C, Damas F, Dawes H, De Keyser V, De Luca A, de Ruiter GC, De Witte O, Della Corte F, Demeter B, Depreitere B, Dippel DW, Dizdarevic K, Dreier JP, Eapen G, Ercole A, Esser P, Fabricius M, Feremans L, Feigin VL, Fossi F, Forsyth F, Florian S, Frisvold SK, Frosini C, Furmanov A, Frantzén J, Gadda D, Gagliardo P, Galanaud D, Gao G, Ghuysen A, Godbolt A, Gonšorová V, Grigore Z, Gruen R, Haagsma JA, Hallaert G, Hadzic E, Haitsma I, Hartings JA, Helbok R, Helseth E, Hill S, Hoefer S, Holling M, Hunfeld M, Hutchinson PJ, Illéš R, Janssens K, Bovend’Eerdt TJ, Jiang JY, Jones KM, Kalala JP, Kalovits F, Kasprian G, Katila A, Ketharanathan N, Kolias AG, Kolibay F, Kondziella D, Koskinen LO, Lagares A, Lanyon L, Laureys S, Lecky F, Lefering R, Levi L, Lightfoot R, Lingsma HF, Loeckx D, Lohkamp LN, Lötjönen J, Lumenta C, Lyttle M, Maas A, Maegele M, Majdan M, Manara A, Manley GT, Maréchal H, Martino C, Mascia L, Mauritz W, McMahon C, Menon DK, Menovsky T, Mitchell P, Mladenov N, Morganti-Kossmann C, Nelson D, Neugebauer E, Newcombe VF, Oddo M, Oresic M, Orzalesi V, Outtrim JG, Palotie A, Parizel P, Payen JF, Perlbarg V, Peul W, Pichon N, Piippo A, Floury SP, Ples H, Polinder S, Preiksaitis A, Psota M, Pullens P, Puybasset L, Ragauskas A, Raj R, Reiner M, Rhodes JK, Richardson S, Ripatti S, Rocka S, Roosenfeld J, Rosand J, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rueckert D, Rusnák M, Rynkowski MA, Sahuquillo J, Sakowitz O, Sandor J, Schmidt S, Schoechl H, Schou R, Skandsen T, Sonne M, Schwendenwein E, Smeets D, Smieleweski P, Söderberg J, Stamatakis E, Stanworth S, Stefini R, Stevens R, Stewart W, Steyerberg EW, Stocchetti N, Stummer W, Szabó J, Tascu A, Tenovuo O, Theadom A, Tibboel D, Tolias CM, Unterberg A, Vajkoczy P, Vargiolu A, van der Naalt J, van Essen T, Van Hecke W, Van Praag D, Van Roost D, Vandenbulcke T, vandeHauwe L, Van der Jagt M, Vega E, Verheyden J, Verma V, Vespa PM, Vik A, Vilcinis R, von Steinbüchel N, Vulekovic P, Wang KK, Wildschut E, Williams G, Wilson M, Wilson L, Wolf S, Ylén P, Zaaroor M, Zolfaghari P, Martin D, D’Orio V, Damas P, Tshibanda JF.

Abstract

BACKGROUND:

Current classification of traumatic brain injury (TBI) is suboptimal, and management is based on weak evidence, with little attempt to personalize treatment. A need exists for new precision medicine and stratified management approaches that incorporate emerging technologies.

OBJECTIVE:

To improve characterization and classification of TBI and to identify best clinical care, using comparative effectiveness research approaches.

METHODS:

This multicenter, longitudinal, prospective, observational study in 22 countries across Europe and Israel will collect detailed data from 5400 consenting patients, presenting within 24 hours of injury, with a clinical diagnosis of TBI and an indication for computed tomography. Broader registry-level data collection in approximately 20,000 patients will assess generalizability. Cross sectional comprehensive outcome assessments, including quality of life and neuropsychological testing, will be performed at 6 months. Longitudinal assessments will continue up to 24 months post TBI in patient subsets. Advanced neuroimaging and genomic and biomarker data will be used to improve characterization, and analyses will include neuroinformatics approaches to address variations in process and clinical care. Results will be integrated with living systematic reviews in a process of knowledge transfer. The study initiation was from October to December 2014, and the recruitment period was for 18 to 24 months.

EXPECTED OUTCOMES:

Collaborative European NeuroTrauma Effectiveness Research in TBI should provide novel multidimensional approaches to TBI characterization and classification, evidence to support treatment recommendations, and benchmarks for quality of care. Data and sample repositories will ensure opportunities for legacy research.

DISCUSSION:

Comparative effectiveness research provides an alternative to reductionistic clinical trials in restricted patient populations by exploiting differences in biology, care, and outcome to support optimal personalized patient management.

 

TRIAL REGISTRATION:

ClinicalTrials.gov NCT02210221.

Neuroretinal rim area and ocular haemodynamic parameters in patients with normal-tension glaucoma with differing intracranial pressures. 2017-12-12T18:51:36+00:00

Br J Ophthalmol. 2016 Aug;100(8):1134-8. doi: 10.1136/bjophthalmol-2015-307570. Epub 2015 Nov 23.

Siaudvytyte L1, Januleviciene I1, Daveckaite A1, Ragauskas A2, Siesky B3, Harris A3.

Abstract

PURPOSE:

To assess the differences in the neuroretinal rim area (NRA) and ocular haemodynamic parameters in patients with normal-tension glaucoma (NTG) with differing intracranial pressure (ICP) values.

METHODS:

40 patients (11 males) with NTG (age 61.1 (11.5)) were included in the prospective study. Intraocular pressure (IOP), non-invasive ICP, retrobulbar blood flow (RBF) and confocal laser scanning tomography for optic nerve disc (OND) structural parameters were assessed. Non-invasive ICP was measured using a novel two-depth Transcranial Doppler device. RBF was measured using colour Doppler imaging in the ophthalmic artery (OA). The patients were divided into two groups, ICP ≥ and <8.3 mm Hg, based on the statistical median of ICP. p Values <0.05 were considered statistically significant.

RESULTS:

Patients with NTG had mean ICP 8.8 (2.5) mm Hg, IOP 13.6 (2.1) mm Hg, OND size 2.3 (0.6) mm(2), NRA 1.2 (0.4) mm(2). Lower ICP was correlated with decreased NRA (r=0.51, p=0.001). Patients with NTG having lower ICP (N=20) had significantly lower NRA 1.0 (0.3) mm(2), than patients with NTG having higher ICP (N=20) 1.3 (0.3) mm(2), p=0.002, although there were no significant differences in OND size (accordingly, 2.2 (0.5) and 2.3 (0.6) mm(2), p=0.55) and IOP (accordingly, 13.5 (2.4) and 13.7 (1.8) mm Hg, p=0.58). Patients with NTG having lower ICP had significantly lower OA blood flow velocities (peak systolic volume (PSV) 28.7 (8.0), end-diastolic volume (EDV) 6.9 (3.0) cm/s), compared with patients with NTG having higher ICP (PSV 35.5 (10.2), EDV 9.4 (4.1) cm/s), p<0.04.

CONCLUSIONS:

Patients with NTG having lower ICP have decreased neuroretinal rim area and OA blood flow parameters compared with patients having higher ICP. Further longitudinal studies are needed to analyse the involvement of ICP in NTG management.

Published by the BMJ Publishing Group Limited. For permission to use (where not already granted under a licence) please go to http://www.bmj.com/company/products-services/rights-and-licensing/

KEYWORDS:

Glaucoma

Association of Severe Traumatic Brain Injury Patient Outcomes With Duration of Cerebrovascular Autoregulation Impairment Events. 2017-12-12T18:50:30+00:00

Neurosurgery. 2016 Jul;79(1):75-82. doi: 10.1227/NEU.0000000000001192.

Preiksaitis A1, Krakauskaite S, Petkus V, Rocka S, Chomskis R, Dagi TF, Ragauskas A.

Abstract

BACKGROUND:

Cerebrovascular autoregulation (CA) is an important hemodynamic mechanism that protects the brain against inappropriate fluctuations in cerebral blood flow in the face of changing cerebral perfusion pressure. Temporal CA failure is associated with worse outcomes in various acute neurological diseases. An integrative approach is presently used according to the existing paradigm for the association of series of temporal CA impairments with the outcomes of patients with traumatic brain injury (TBI).

OBJECTIVE:

To explore the influence of the duration of CA impairment events on severe TBI patient outcomes. Patient age was also included in the analysis of the prospectively collected clinical data.

METHODS:

CA monitoring included 33 prospective severe TBI patients. The pressure reactivity index [PRx(t)] was continuously monitored to collect information on the dynamics of CA status and to analyze associations between the duration of the longest CA impairment event and patient outcomes.

RESULTS:

The Glasgow outcome scale and the duration of the longest CA impairment were negatively correlated. The duration of autoregulation impairment significantly correlated with worse outcomes. Multidimensional representation of Glasgow outcome scale plots showed that better outcomes were obtained for younger patients (age < 47 years) and those whose longest CA impairment event was shorter than 40 minutes if PRx(t) was above 0.7 in the CA impairment event.

CONCLUSION:

Unfavorable outcomes for TBI patients are more significantly associated with the duration of the single longest CA impairment episode at a high PRx(t) value, rather than with averaged PRx(t) values or the average time of all CA impairment episodes.

ABBREVIATIONS:

ABP, arterial blood pressureABP(t), continuous reference arterial blood pressureCA, cerebrovascular autoregulationCBF, cerebral blood flowCPP, cerebral perfusion pressureGOS, Glasgow outcome scaleGOSHD, Glasgow outcome scale after hospital dischargeGOS6M, Glasgow outcome scale at 6 months after dischargeICP, intracranial pressureICP(t), continuously monitored intracranial pressureLCAI, longest CA impairmentoptCPP, optimal cerebral perfusion pressurePRx(t), pressure reactivity indexTBI, traumatic brain injury.

Association between the outcome of traumatic brain injury patients and cerebrovascular autoregulation, cerebral perfusion pressure, age, and injury grades. 2017-12-12T18:48:13+00:00

Medicina (Kaunas). 2016;52(1):46-53. doi: 10.1016/j.medici.2016.01.004. Epub 2016 Jan 28.

Petkus V1, Krakauskaitė S2, Preikšaitis A3, Ročka S3, Chomskis R2, Ragauskas A2.

Abstract

BACKGROUND AND OBJECTIVE:

The aim of this study was to explore the association of cerebrovascular autoregulation (CA) and optimal cerebral perfusion pressure (CPP) managing conditions with the outcome of traumatic brain injury (TBI) patients including additional information about the patients’ age and grade of diffuse axonal injury (DAI).

MATERIALS AND METHODS:

The CA monitoring of 28 TBI patients was performed by using ICM+ software (Cambridge, UK). The CA status estimating pressure reactivity indexes (PRx) and CPP data were processed in order to obtain information on the patient-specific treatment conditions by calculating the optimal CPP.

RESULTS:

There was a negative correlation between the Glasgow outcome scale (GOS) score and PRx (r=-0.448 at hospital discharge and r=-0.402 after 6 months). The estimated threshold value PRx of >0.24 was associated with mortality. The correlation coefficients between the GOS score and the difference CPP-optimal CPP were 0.549 at hospital discharge and 0.484 after 6 months. The threshold value of CPP declination from ΔCPPopt per -6mmHg was associated with mortality. Poorer outcome was predicted for elderly TBI patients (aged >47 years) and patients having a DAI grade of 3.

CONCLUSIONS:

The association of the GOS score with CPP, CA impairment conditions, age and diffuse axonal injury (DAI) grade showed that the outcomes of TBI patients were associated with patient-specific CPP management and better outcomes were obtained for younger patients, for patients having lower DAI grade and for patients whose CPP was kept within the range from the optimal CPP to the optimal CPP+10mmHg.

Copyright © 2016 The Lithuanian University of Health Sciences. Production and hosting by Elsevier Urban & Partner Sp. z o.o. All rights reserved.

 

KEYWORDS:

Cerebrovascular autoregulation monitoring; Optimal cerebral perfusion pressure; Outcome; Traumatic brain injury

Can intracranial pressure be measured non-invasively bedside using a two-depth Doppler-technique? 2017-12-12T18:46:35+00:00

J ClinMonitComput. 2017 Apr;31(2):459-467. doi: 10.1007/s10877-016-9862-4. Epub 2016 Mar 14.

Koskinen LD1, Malm J2, Zakelis R3, Bartusis L3, Ragauskas A3, Eklund A4.

Abstract

Measurement of intracranial pressure (ICP) is necessary in many neurological and neurosurgical diseases. To avoid lumbar puncture or intracranial ICP probes, non-invasive ICP techniques are becoming popular. A recently developed technology uses two-depth Doppler to compare arterial pulsations in the intra- and extra-cranial segments of the ophthalmic artery for non-invasive estimation of ICP. The aim of this study was to investigate how well non-invasively-measured ICP and invasively-measured cerebrospinal fluid (CSF) pressure correlate. We performed multiple measurements over a wide ICP span in eighteen elderly patients with communicating hydrocephalus. As a reference, an automatic CSF infusion apparatus was connected to the lumbar space. Ringer’s solution was used to create elevation to pre-defined ICP levels. Bench tests of the infusion apparatus showed a random error (95 % CI) of less than ±0.9 mmHg and a systematic error of less than ±0.5 mmHg. Reliable Doppler signals were obtained in 13 (72 %) patients. An infusion test could not be performed in one patient. Thus, twelve patients and a total of 61 paired data points were studied. The correlation between invasive and non-invasive ICP measurements was good (R = 0.74), and the 95 % limits of agreements were -1.4 ± 8.8 mmHg. The within-patient correlation varied between 0.47 and 1.00. This non-invasive technique is promising, and these results encourage further development and evaluation before the method can be recommended for use in clinical practice.

KEYWORDS:

Infusion test; Intracranial pressure; Non-invasive ICP; Ophthalmic artery; Transcranial-Doppler

Accuracy, Precision, Sensitivity, and Specificity of Noninvasive ICP Absolute Value Measurements. 2017-12-12T18:08:37+00:00

ActaNeurochir Suppl. 2016;122:317-21. doi: 10.1007/978-3-319-22533-3_63.

 

Krakauskaite S1, Petkus V1, Bartusis L1, Zakelis R1, Chomskis R1, Preiksaitis A2,3, Ragauskas A4, Matijosaitis V5, Petrikonis K5, Rastenyte D5.

 

Abstract

 

An innovative absolute intracranial pressure (ICP) value measurement method has been validated by multicenter comparative clinical studies. The method is based on two-depth transcranial Doppler (TCD) technology and uses intracranial and extracranial segments of the ophthalmic artery as pressure sensors. The ophthalmic artery is used as a natural pair of “scales” that compares ICP with controlled pressure Pe, which is externally applied to the orbit. To balance the scales, ICP = Pe a special two-depth TCD device was used as a pressure balance indicator. The proposed method is the only noninvasive ICP measurement method that does not need patient-specific calibration.

 

KEYWORDS:

Bland–Altman analysis; Noninvasive ICP absolute value method; ROC analysis; Regression analysis; Two-depth transcranial Doppler meter

Benefit on optimal cerebral perfusion pressure targeted treatment for traumatic brain injury patients. 2017-12-12T18:07:38+00:00

J Crit Care. 2017 Oct;41:49-55. doi: 10.1016/j.jcrc.2017.04.029. Epub 2017 Apr 23.

 

Petkus V1, Preiksaitis A2, Krakauskaite S3, Zubaviciute E4, Rocka S5, Rastenyte D6, Vosylius S5, Ragauskas A1.

 

Abstract

 

PURPOSE:

The maintenance of patient-specific optimal cerebral perfusion pressure (CPPopt) is crucial for patients with traumatic brain injury (TBI). The goal of the study was to explore the influence of CPP declination from CPPopt value on the TBI patients’ outcome.

METHODS:

The CPP and cerebrovascular autoregulation (CA) monitoring of 52 TBI patients was performed. Patient-specific CPPopt has been identified and the associations between the patients’ outcome and complex influence of time of CPP declination from CPPopt value, age, and the duration of CA impairment episodes has been analyzed.

RESULTS:

The multiple correlation coefficient between the Glasgow outcome scale (GOS), duration of CA impairment events and percentage time, when 0<ΔCPPopt<10mmHg was r=-0.643 (P<0.001). The multiple correlation coefficients between GOS, age, and percentage time of ΔCPPopt when 0<ΔCPPopt<10mmHg was r=-0.587 (P<0.001).

CONCLUSION:

The CPPopt-targeted patient-specific management might be useful for stabilizing CA in TBI patients as well as for improving their outcome. Better outcomes were obtained by maintaining CPP in light hyperperfusion condition (up to 10mmHg above CPPopt) when CPPopt is in the range of 60-80mmHg, and keeping CPP within the range of CPPopt +/-5mmHg when CPPopt is above 80mmHg.

Copyright © 2017 Elsevier Inc. All rights reserved.

 

KEYWORDS:

Cerebrovascular autoregulation; Cerebrovascular reactivity; Optimal cerebral perfusion pressure; Traumatic brain injury

Variation in monitoring and treatment policies for intracranial hypertension in traumatic brain injury: a survey in 66 neurotrauma centers participating in the CENTER-TBI study. 2017-12-12T18:05:49+00:00

Crit Care. 2017 Sep 6;21(1):233. doi: 10.1186/s13054-017-1816-9.

 

Cnossen MC1, Huijben JA2, van der Jagt M3, Volovici V2,4, van Essen T5, Polinder S2, Nelson D6, Ercole A7, Stocchetti N8,9, Citerio G10,11, Peul WC5,12, Maas AIR13, Menon D7, Steyerberg EW2,14, Lingsma HF2; CENTER-TBI investigators.

Collaborators (322)

Adams H, Alessandro M, Allanson J, Amrein K, Andaluz N, Andelic N, Andrea N, Andreassen L, Anke A, Antoni A, Ardon H, Audibert G, Auslands K, Azouvi P, Baciu C, Bacon A, Badenes R, Baglin T, Bartels R, Barzó P, Bauerfeind U, Beer R, Belda FJ, Bellander BM, Belli A, Bellier R, Benali H, Benard T, Berardino M, Beretta L, Beynon C, Bilotta F, Binder H, Biqiri E, Blaabjerg M, Borgen LS, Bouzat P, Bragge P, Brazinova A, Brehar F, Brorsson C, Buki A, Bullinger M, Bučková V, Calappi E, Cameron P, Lozano GC, Carise E, Carpenter K, Castaño-León AM, Causin F, Chevallard G, Chieregato A, Citerio G, Cnossen M, Coburn M, Coles J, Cooper JD, Correia M, Covic A, Curry N, Czeiter E, Czosnyka M, Dahyot-Fizelier C, Damas F, Damas P, Dawes H, De Keyser V, Corte FD, Depreitere B, Ding S, Dippel D, Dizdarevic K, Dulière GL, Dzeko A, Eapen G, Engemann H, Ercole A, Esser P, Ezer E, Fabricius M, Feigin VL, Feng J, Foks K, Fossi F, Francony G, Frantzén J, Freo U, Frisvold S, Furmanov A, Gagliardo P, Galanaud D, Gao G, Geleijns K, Ghuysen A, Giraud B, Glocker B, Gomez PA, Grossi F, Gruen RL, Gupta D, Haagsma JA, Hadzic E, Haitsma I, Hartings JA, Helbok R, Helseth E, Hertle D, Hill S, Hoedemaekers A, Hoefer S, Hutchinson PJ, Håberg AK, Jacobs B, Janciak I, Janssens K, Jiang JY, Jones K, Kalala JP, Kamnitsas K, Karan M, Karau J, Katila A, Kaukonen M, Keeling D, Kerforne T, Ketharanathan N, Kettunen J, Kivisaari R, Kolias AG, Kolumbán B, Kompanje E, Kondziella D, Koskinen LO, Kovács N, Kálovits F, Lagares A, Lanyon L, Laureys S, Lauritzen M, Lecky F, Ledig C, Lefering R, Legrand V, Lei J, Levi L, Lightfoot R, Lingsma H, Loeckx D, Lozano A, Luddington R, Luijten-Arts C, Andrew IRM, MacDonald S, MacFayden C, Maegele M, Majdan M, Major S, Manara A, Manhes P, Manley G, Martin D, Martino C, Maruenda A, Maréchal H, Mastelova D, Mattern J, McMahon C, Melegh B, Menon D, Menovsky T, Morganti-Kossmann C, Mulazzi D, Mutschler M, Mühlan H, Negru A, Nelson D, Neugebauer E, Newcombe V, Noirhomme Q, Nyirádi J, Oddo M, Oldenbeuving A, Oresic M, Ortolano F, Palotie A, Parizel PM, Patruno A, Payen JF, Perera N, Perlbarg V, Persona P, Peul W, Pichon N, Piilgaard H, Piippo A, Floury SP, Pirinen M, Ples H, Polinder S, Pomposo I, Psota M, Pullens P, Puybasset L, Ragauskas A, Raj R, Rambadagalla M, Rehorčíková V, Rhodes J, Richardson S, Ripatti S, Rocka S, Rodier N, Roe C, Roise O, Roks G, Romegoux P, Rosand J, Rosenfeld J, Rosenlund C, Rosenthal G, Rossaint R, Rossi S, Rostalski T, Rueckert D, de Arcaute FR, Rusnák M, Sacchi M, Sahakian B, Sahuquillo J, Sakowitz O, Sala F, Sanchez-Pena P, Sanchez-Porras R, Sandor J, Santos E, Sasse N, Sasu L, Savo D, Schipper I, Schlößer B, Schmidt S, Schneider A, Schoechl H, Schoonman G, Schou RF, Schwendenwein E, Schöll M, Sir Ö, Skandsen T, Smakman L, Smeets D, Smielewski P, Sorinola A, Stamatakis E, Stanworth S, Stegemann K, Steinbüchel N, Stevens R, Stewart W, Steyerberg EW, StocchettiN, Sundström N, Synnot A, Szabó J, Söderberg J, Taccone FS, Tamás V, Tanskanen P, Tascu A, Taylor MS, TeAo B, Tenovuo O, Teodorani G, Theadom A, Thomas M, Tibboel D, Tolias C, Tshibanda JL, Tudora CM, Vajkoczy P, Valeinis E, Van Hecke W, Van Praag D, Van Roost D, Van Vlierberghe E, Vyvere TV, Vanhaudenhuyse A, Vargiolu A, Vega E, Verheyden J, Vespa PM, Vik A, Vilcinis R, Vizzino G, Vleggeert-Lankamp C, Volovici V, Vulekovic P, Vámos Z, Wade D, Wang KKW, Wang L, Wildschut E, Williams G, Willumsen L, Wilson A, Wilson L, Winkler MKL, Ylén P, Younsi A, Zaaroor M, Zhang Z, Zheng Z, Zumbo F, de Lange S, de Ruiter GCW, den Boogert H, van Dijck J, van Essen TA, van Heugten C, van der Jagt M, van der Naalt J.

 

Abstract

 

BACKGROUND:

No definitive evidence exists on how intracranial hypertension should be treated in patients with traumatic brain injury (TBI). It is therefore likely that centers and practitioners individually balance potential benefits and risks of different intracranial pressure (ICP) management strategies, resulting in practice variation. The aim of this study was to examine variation in monitoring and treatment policies for intracranial hypertension in patients with TBI.

METHODS:

A 29-item survey on ICP monitoring and treatment was developed on the basis of literature and expert opinion, and it was pilot-tested in 16 centers. The questionnaire was sent to 68 neurotrauma centers participating in the Collaborative European Neurotrauma Effectiveness Research in Traumatic Brain Injury (CENTER-TBI) study.

RESULTS:

The survey was completed by 66 centers (97% response rate). Centers were mainly academic hospitals (n = 60, 91%) and designated level I trauma centers (n = 44, 67%). The Brain Trauma Foundation guidelines were used in 49 (74%) centers. Approximately 90% of the participants (n = 58) indicated placing an ICP monitor in patients with severe TBI and computed tomographic abnormalities. There was no consensus on other indications or on peri-insertion precautions. We found wide variation in the use of first- and second-tier treatments for elevated ICP. Approximately half of the centers were classified as using a relatively aggressive approach to ICP monitoring and treatment (n = 32, 48%), whereas the others were considered more conservative (n = 34, 52%).

CONCLUSIONS:

Substantial variation was found regarding monitoring and treatment policies in patients with TBI and intracranial hypertension. The results of this survey indicate a lack of consensus between European neurotrauma centers and provide an opportunity and necessity for comparative effectiveness research.

 

KEYWORDS:

Comparative effectiveness research; ICP; ICU; Intracranial hypertension; Survey; Traumatic brain injury

 

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