Multimodality Monitoring in Neurocritical Care

This is an interesting illustration that puts into perspective the rationale behind multimodal monitoring and why relying on one modality alone will give an imperfect picture of any ongoing intracerebral pathology.

MMM

Do we need a more advanced brain and spinal cord monitoring to follow metabolism and function? To make more concrete the multimodal approach, it is possible to put in accordance the different possible modalities of CNS monitoring to the respective level in the phenomenological chain leading to the highest complexity: the CNS function and neurons functioning, on right.

  1. First, the driving pressure method is based on the usual and continuous monitoring of the ICP and CPP.
  2. Second, about CBF assessment, the TCD remains the reference technique even if local CBF (lCBF) or regional CBF (rCBF) would deserve to be considered a new time.
  3. Third, to follow the 02 delivery, the PbtO2 has progressively supplanted the classical SjvO2, without to be really competed with the cerebral oximetry, remaining an O2 cerebral diffusion indicator rather than a really metabolic parameter.
  4. Fourth, the metabolism is essentially related by the microdialysis technique for which an increased glutamate, a high lactate/pyruvate ratio with a low glucose in the brain relate a CNS cellular hypoxia.
  5. Finally, in point 5, the electrophysiology is alone able to give an idea of the CNS function and neurons functioning.

About the phenomenological chain from point 1 to point 5, each item is required for the further factors downstream as in a sort of cascade. The corresponding monitoring items progress from the most basic (on left) with the simplest interpretation to the most advanced (on right) with more complex results sometime difficult to put in perspective with the patient situation.

Similarly, the impact on the patients’ treatment varies from direct to remote or indirect. However, the level of the accuracy of the information’s given by the successive monitoring’s is progressively growing up, counterbalancing the apparent awkwardness of use. The investment of time to know how to use the different modalities of this monitoring would be always very productive and beneficial either for the clinicians or particularly for the patients.[1]

 

BRAIN MONITORING

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Multi-modality Monitoring Goals:

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A helpful table on MMM from a recent article by Roh, et al:

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And another table from the same article that describes non-invasive MMM monitors:

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Finally, here is a graph showing how multimodality monitoring can be used in the treatment of a high grade SAH.  The graph starts on Day 3 where abnormalities were seen in PbtO2 (low), ICP (high) and CPP (low).  There was no clinical evidence of decline at this point.  CTA done on day 5 (dotted line) revealed vasospasm and hyperosmolar therapy and hemodynamic augmentation was started to CPP (>100) and PbtO2  (normalization) goals.

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This table shows the multimodality monitoring components recommended for high-grade SAH:

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mmm-for-high-grade-sah


Summary  of graphs show interrelationship between brain monitoring parameters. As ICP increase become sustained, notice drop in CPP with corresponding subsequent decrease in CSF glucose. LPR remains consistently elevated.

 

CMA 600 Microdialysis Analyzer (user manual)

References

[1] Pandin, Pierre et al. ‘Monitoring Brain And Spinal Cord Metabolism And Function’. Open Journal of Anesthesiology 04.06 (2014): 131-152.

Clinicalgate.com,. “Principles Of Neurointensive Care | Clinical Gate”. N.p., 2016.

Lee, Kiwon et al. “Perioperative Critical Care Management For Patients With Aneurysmal Subarachnoid Hemorrhage”. Korean Journal of Anesthesiology 67.2 (2014): 77.

Roh, David and Soojin Park. “Brain Multimodality Monitoring: Updated Perspectives”. Current Neurology and Neuroscience Reports 16.6 (2016):

Francoeur, Charles L. and Stephan A. Mayer. “Management Of Delayed Cerebral Ischemia After Subarachnoid Hemorrhage”. Critical Care 20.1 (2016).

Tasneem, Nudrat et al. “Brain Multimodality Monitoring: A New Tool In Neurocritical Care Of Comatose Patients”. Critical Care Research and Practice 2017 (2017): 1-8.

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