Is Neuromonitoring an expensive waste of time, in Severe Traumatic Brain Injury?

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1 Is Neuromonitoring an expensive waste of time, in Severe Traumatic Brain Injury? Edema Engorgement Contusion Hematoma Hypoxia Diffuse Axonal Injury Ross Bullock, MD, PhD. Director, Neurotrauma,- University of Miami /Jackson Memorial Hospital, Miami.

2 Subcellular mechanisms, in TBI, SAH, ICH, Stroke..

3 Monitors alone cannot save patients, but wise application of the data from monitoring the injured brain can.. Saul, Ducker,1983 Monitoring, vs serial imaging..?

4 Severe TBI-- Does it all make a difference? Mortality rates falling.~80% before WWII.. 60% in 1960 s, 40% in 1980 s ~20% in Most cost effective surgical procedure of all is craniotomy for EDH Probability of death severe TBI Probability of outcome (%) Age (years)

5 Substrate delivery Monitoring pannecrosis Ischemic Tissue Damage and Infarction is Dependent on Reduction of Oxygen Delivery and the Duration of the Ischemic Insult

6 Why is ICP Monitoring so Important? 80% in hospital deaths from high ICP. barometer of standard of care level II guideline.. Best way to implement more ICP monitoring, maybe by concentrating patients at hospitals who do it.?? Gold book requirement for Level 1 centers

7 Neuromonitoring Methods Functional status of the CNS GCS, Neuro exam, EEG, Evoked potentials, EcoG, Pupillometer, Substrate delivery to the injured Brain. -CBF, ICP, CPP, MABP, PtiO2, Jugular Bulb oximetry, AVDO2, NIR spectroscopy, Microdialysis, Combined methods Brain Biomarkers --the future??? S100B, alpha Spectrin,beta amyloid..

8 The NIH-NINDS Trial of ICP Monitoring, in Bolivia,LABIC 4 hospitals, PRCT..~350 pts

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10 We are still likely to continue to doubt clinical signs, which indeed do not reflect global pressure inside the cranium, but stupor, coma, posturing, and dilatation of the pupils indicate compression of the midbrain, and according to this study they are very suitable observations to use in directing treatment. In the future there may be other means of detecting early compression of the brain stem. Until then, clinical methods are fine.

11 Why the Chesnut Bolivia ICP monitoring trial is not generalisable, to rest of the world Only about 50% of severe TBI cases, got into ICU bed limitations No prehospital care, no rehab, poor subacute phase care..40% mortality ~47% decompressive craniotomy used, in both groups, ~23% barbiturates, 1% ventricular drainage.. mean~ 20 hours, with ICP>20mmHg..

12 Increased mortality in patients with severe traumatic brain injury treated without intracranial pressure monitoring Arash Farahvar, M.D., Ph.D.,1 Linda M. Gerber, Ph.D.,2 Ya-Lin Chiu, M.S.,2 Nancy Carney, Ph.D.,3 Roger Härtl, M.D.,4 and Jam shid Ghaja r, M.D., Ph.D.4,5 1Department of Neurosurgery, University of Rochester Medical Center, Rochester; Departments of 2Public Health and 4Neurological Surgery, Weill Cornell Medical College; and 5Brain Trauma Foundation, New York, New York; and 3Department of Medical Informatics and Clinical Epidemiology, Oregon Health & Science University, Portland, Oregon Object. Evidence-based guidelines recommend intracranial pressure (ICP) monitoring for patients with severe traumatic brain injury (TBI), but there is limited evidence that monitoring and treating intracranial hypertension reduces mortality. This study uses a large, prospectively collected database to examine the effect on 2-week mortality of ICP reduction therapies administered to patients with severe TBI treated either with or without an ICP monitor. Methods. From a population of 2134 patients with severe TBI (Glasgow Coma Scale [GCS] Score < 9), 1446 patients were treated with ICP-lowering therapies. Of those, 1202 had an ICP monitor inserted and 244 were treated without monitoring. Patients were admitted to one of 20 Level I and two Level II trauma centers, part of a New York State quality improvement program administered by the Brain Trauma Foundation between 2000 and Results. Age, initial GCS score, hypotension, and CT scan findings were associated with 2-week mortality. In addition, patients of all ages treated with an ICP monitor in place had lower mortality at 2 weeks (p = 0.02) than those treated without an ICP monitor, after adjusting for parameters that independently affect mortality. Conclusions. In patients with severe TBI treated for intracranial hypertension, the use of an ICP monitor is associated with significantly lower mortality when compared with patients treated without an ICP monitor. Based on these findings, the authors conclude that ICP-directed therapy in patients with severe TBI should be guided by ICP monitoring. (

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14 Neuromonitoring Methods Functional status of the CNS GCS, Neuro exam, EEG, Evoked potentials, EcoG, Pupillometer, Substrate delivery to the injured Brain. -CBF, ICP, CPP, MABP, PtiO2, Jugular Bulb oximetry, AVDO2, NIR spectroscopy, Microdialysis, Combined methods Brain Biomarkers --the future??? S100B, alpha Spectrin,beta amyloid..

15 Increased Related incidence Articles, and Links impact of nonconvulsive and convulsive seizures after traumatic brain injury as detected by continuous electroencephalographic monitoring. Vespa PM, Nuwer MR, Nenov V, Ronne-Engstrom E, Hovda DA, Bergsneider M, Kelly DF, Martin NA, Becker DP. Department of Neurology, University of California at Los Angeles School of Medicine, 90024, USA. Convulsive and nonconvulsive seizures occurred in 21 (22%) of the 94 patients, with six of them displaying status epilepticus. In more than half of the patients (52%) the seizures were nonconvulsive and were diagnosed on the basis of EEG studies alone. All six patients with status epilepticus died, compared with a mortality rate of 24% (18 of 73) in the nonseizure group (p<0.001). The patients with status epilepticus had a shorter mean length of stay (9.14+/-5.9 days compared with 14+/-9 days [t-test, p<0.031). Seizures occurred despite initiation of prophylactic phenytoin on admission to the emergency room, with maintenance at mean levels of 16.6+/-2.8 mg/dlconclusions: Seizures occur in more than one in five patients during the 1st week after moderate-to-severe brain injury and may play a role in the pathobiological conditions associated with brain injury. J Neurosurg Nov;91(5):

16 Human TBI and COSBID.. suppression of large amplitude delta activity (e.g. PLEDs) EEG 1 s 1 min DC Temperature ranges All temps during monitoring Temp during CSD N=~130, USA/EU < % 10% % 23% > % 68% Chi-square p<0.001

17 Univariate Analysis-outcome Explained Variance Nagelkerke s R * * * *Significance at p<0.05

18 :00 0:00 6:00 12:00 18:00 0:00 6:00 12:00 18:00 0:00 6:00 12:00 18:00 0:00 6:00

19 Synergistic pathomechanisms are commonest Do we need synergistic THERAPIES For multiple damage Mechanisms?

20 Tissue Oxygen Tension in Humans after TBI Between 6-24 h after Injury Brain tissue oxygen tension (PtiO2) H Brain po2 Outcome <20 mmhg Poor mmhg Moderate >30 mmhg Good Between h after Injury Brain tissue oxygen tension (PtiO2)

21 Reduced mortality rate in patients with severe traumatic brain injury treated with brain tissue oxygen monitoring M STIEFEL, M.D., PH.D., M. S GRADY, M.D., AND P D. LE ROUX, M.D. U Penn J Neurosurg 103: , 2005 Patients treated with ICP and brain tissue PO2 monitoring were compared with historical controls PtO2 Therapy in both patient groups was aimed at maintaining an ICP less than 20 mm Hg and a CPP greater than 60 mm Hg. Among patients whose brain tissue PO2 was monitored, oxygenation was maintained at levels greater than 25 mm Hg The mortality rate in patients treated using conventional ICP and CPP management was 44%. Patients who also underwent brain tissue PO2 monitoring had a significantly reduced mortality rate of 25% (p 0.05).

22 TBI Clinical Trials--ongoing.2013 Clinical trials.gov n= 762 (n= 307 in 2010) DOD effect $120M in observational. Brain 0xygen directed therapy BOOST..UT NIH COSBID EcoG for Spreading depolarisations.. IMPACT TRACK II-III Non invasive ICP.. ECHODIA system..x2 PET to trace Neuroinflammation in STBI..NIH

23 CBF monitoring Transcranial Doppler Monitoring Easy to use, noninvasive, repeatable Measures basal cerebral bld flow velocity flow via doppler equation Used to differentiate vasospasm from hyperaemia (Lindegaard Index)

24 What has been achieved, by monitoring the injured Brain? Improved understanding of dynamic pathophysiology, after HUMAN TBI, SAH.. Guide design of neuroprotection trials Improved patient outcome???? Death rate severe TBI 100 Probability of outcome (%) Age (years)

25 Australia and NZ The Alfred Royal Melbourne Hospital Royal Adelaide Hospital Royal Perth Hospital Sir Charles Gairdner Hospital Nepean Hospital John Hunter Hospital Royal North Shore Hospital Liverpool Hospital Wollongong Hospital Princess Alexandra Hospital Gold Coast Hospital Flinders Medical Centre Auckland Hospital Waikato Hospital Wellington Hospital Early bifrontal decompression, Vs medical management No benefit from surgery more disabled and vegetative outcomes.. Saudi Arabia King Fahad National Guard Hospital Canada Hamilton General hospital Vancouver General Hospital Sunnybrook Medical Centre Royal Columbian Hospital India Christian Medical College, Ludhiana

26 3 editorials, on the DECRA tria

27 Jiang et al, 2005 Effect of Standard Trauma Craniotomy, for refractory ICP with severe TBI-a multicenter Prospective randomised controlled study J Neurotrauma,22: Study design:-486 patients.. Blinded assessment of outcomes Randomization completed in blocks of 5, stratified according to center Compared bone flaps of dimension 12x15cm vs. 6x8cm Necrotic tissue debrided Dura closure with graft to expand Otherwise managed as per 1996 AANS guidelines for head trauma Blinded physiatrist performed follow-up exam at 6 months after injury

28 Cambridge 34 Leeds 20 Royal London 12 Newcastle 11 Southampton 10 Singapore 8 Milan, Italy 6 Manchester 6 Saudi Arabia 5 Edmonton, Canada 5 Calgary, Canada 4 Hong-Kong 4 Old Church 4 Plymouth 4 Hurstwood Park 3 Kings College 3 Pavia, Italy 3 Barcelona, Spain 2 Livorno, Italy 1 Malaysia 1 Oxford 1 Queen s Square 1 Swansea 1 Ulm, Germany patients recruited, -january 2013! Results early Unilateral large DC, Includes High ICP Due to contusions,

29 R 21 Grant, NIH NINDS RNS069309ACapacity building for Decompressive Craniotomy, in Colombia The objective of this proposal is to create a standardized protocol for DC implementation with subsequent implementation of the protocol in three hospitals in Colombia. The initial pilot study will accrue 40 adult patients with severe TBI and evaluate outcomes over a 2 year period using the data registry.