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Accuracy of Brain Multimodal Monitoring to Detect Cerebral Hypoperfusion After Traumatic Brain Injury*

Bouzat, Pierre MD, PhD1,2; Marques-Vidal, Pedro MD, MPH3; Zerlauth, Jean-Baptiste MD4; Sala, Nathalie MD1; Suys, Tamarah RN, MPH1; Schoettker, Patrick MD5; Bloch, Jocelyne MD6; Daniel, Roy T. MD6; Levivier, Marc MD6; Meuli, Reto MD4; Oddo, Mauro MD1

doi: 10.1097/CCM.0000000000000720
Neurologic Critical Care
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Objective: To examine the accuracy of brain multimodal monitoring—consisting of intracranial pressure, brain tissue PO2, and cerebral microdialysis—in detecting cerebral hypoperfusion in patients with severe traumatic brain injury.

Design: Prospective single-center study.

Patients: Patients with severe traumatic brain injury.

Setting: Medico-surgical ICU, university hospital.

Intervention: Intracranial pressure, brain tissue PO2, and cerebral microdialysis monitoring (right frontal lobe, apparently normal tissue) combined with cerebral blood flow measurements using perfusion CT.

Measurements and Main Results: Cerebral blood flow was measured using perfusion CT in tissue area around intracranial monitoring (regional cerebral blood flow) and in bilateral supra-ventricular brain areas (global cerebral blood flow) and was matched to cerebral physiologic variables. The accuracy of intracranial monitoring to predict cerebral hypoperfusion (defined as an oligemic regional cerebral blood flow < 35 mL/100 g/min) was examined using area under the receiver-operating characteristic curves. Thirty perfusion CT scans (median, 27 hr [interquartile range, 20–45] after traumatic brain injury) were performed on 27 patients (age, 39 yr [24–54 yr]; Glasgow Coma Scale, 7 [6–8]; 24/27 [89%] with diffuse injury). Regional cerebral blood flow correlated significantly with global cerebral blood flow (Pearson r = 0.70, p < 0.01). Compared with normal regional cerebral blood flow (n = 16), low regional cerebral blood flow (n = 14) measurements had a higher proportion of samples with intracranial pressure more than 20 mm Hg (13% vs 30%), brain tissue PO2 less than 20 mm Hg (9% vs 20%), cerebral microdialysis glucose less than 1 mmol/L (22% vs 57%), and lactate/pyruvate ratio more than 40 (4% vs 14%; all p < 0.05). Compared with intracranial pressure monitoring alone (area under the receiver-operating characteristic curve, 0.74 [95% CI, 0.61–0.87]), monitoring intracranial pressure + brain tissue PO2 (area under the receiver-operating characteristic curve, 0.84 [0.74–0.93]) or intracranial pressure + brain tissue PO2+ cerebral microdialysis (area under the receiver-operating characteristic curve, 0.88 [0.79–0.96]) was significantly more accurate in predicting low regional cerebral blood flow (both p < 0.05).

Conclusion: Brain multimodal monitoring—including intracranial pressure, brain tissue PO2, and cerebral microdialysis—is more accurate than intracranial pressure monitoring alone in detecting cerebral hypoperfusion at the bedside in patients with severe traumatic brain injury and predominantly diffuse injury.

1Department of Intensive Care Medicine, Neuroscience Critical Care Research Group, CHUV-Lausanne University Hospital, Faculty of Biology and Medicine, Lausanne, Switzerland.

2Joseph Fourier University, Grenoble, France.

3Department of Internal Medicine, CHUV-Lausanne University Hospital, Faculty of Biology and Medicine, Lausanne, Switzerland.

4Department of Radiology, CHUV-Lausanne University Hospital, Faculty of Biology and Medicine, Lausanne, Switzerland.

5Department of Anesthesiology, CHUV-Lausanne University Hospital, Faculty of Biology and Medicine, Lausanne, Switzerland.

6Clinical Neurosciences, Division of Neurosurgery, CHUV-Lausanne University Hospital, Faculty of Biology and Medicine, Lausanne, Switzerland.

* See also p. 506.

Dr. Bouzat received research grants from La Fondation des Gueules Cassées. Dr. Oddo received research grants from the Swiss National Science Foundation and the Novartis Foundation for Biomedical Research. The remaining authors have disclosed that they do not have any potential conflicts of interest.

For information regarding this article, E-mail: mauro.oddo@chuv.ch

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