Neurocritical Care and Traumatic Brain Injury*

Date/Time: Tuesday, September 12, 2023 - 11:00 AM – 12:30 PM
Track: Special Interest Group (SIG) Session
Room: Conference Room 404 (4th Floor)
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Chair: Marion S. Buckwalter, MD, PhD

Co-Chair: Danielle K. Sandsmark, MD, PhD

This session will highlight advanced neuroimaging techniques, their use in TBI and neurocritical care, and the evidence that they predict and/or can be used to modify outcomes in patients with critical brain dysfunction. Dr. Lori Shutter, Professor of Critical Care Medicine, Neurology and Neurosurgery Vice Chair for Education, will discuss brain tissue oxygen monitoring in TBI and it’s use in potentially improving outcomes. She will discuss the results of her Phase 2 trial, BOOST 2, and her ongoing Phase 3 trail BOOST 3. Dr. Matt Kirschen is an Assistant Professor in at University of Pennsylvania. He will discuss his work using neuromonitoring, particularly NIRS (near infrared spectroscopy) to predict prognosis after cardiac arrest. In addition, 2-3 short talks on advanced neuromonitoring will be selected from submitted abstracts.

Learning Objectives:

  • Participants will learn about brain tissue oxygen, NIRS, and PRx as measures of brain health.
  • Participants will learn the latest evidence on whether brain tissue oxygen treatment improves neurological outcomes.
  • Participants will learn the latest evidence on whether optimizing cerebral autoregulation improves neurological outcomes.
  • Participants will learn the evidence that NIRS predicts outcomes after cardiac arrest.

NIRS after cardiac arrest

Speaker: Matthew Kirschen, MD, PhD

Will discuss the use of NIRS to personalize care for patients with hypoxic-ischemic brain injury after cardiac arrest. The discussion will include how NIRS can be used to assess cerebral autoregulation and optimal blood pressure during post-arrest care.

Brain tissue oxygen monitoring

Speaker: Lori Shutter, MD, FCCM, FNCS, FANA

This presentation will review the historical data on brain tissue oxygen (PbtO2) monitoring, present information on current PbtO2 studies, and discuss the integration of PbtO2 monitoring into management of critically ill neurological patients.

Current Practice for Continuous EEG Monitoring in the Critically Ill Patient: A Latin American Survey

Oral Abstract Presenter: Clio Rubinos, MD, MS

Background and Purpose: Seizures, clinical and electrographic, are common complications in critically ill patients and are associated with worse outcomes. Continuous electroencephalogram monitoring (cEEG) is the only non-invasive tool for continued brain monitoring. There has been an increased use of cEEG in high-income countries. However, knowledge of the access and use of cEEG in Latin America is scarce. Hence, the objective of this study was to conduct a survey to evaluate practice patterns and access to cEEG monitoring in critically ill patients in Latin America. Methods: We disseminated a web-based, anonymous survey to providers caring for critically ill patients through Latin American Brain Injury Consortium, a large established network of intensivists in LA. The survey consisted of 10 questions and was designed to describe the availability of EEG in LA. Results: Of 182 participants from 17 countries who completed the survey, the majority were intensivists (85.9%) working at public hospitals (61.2%), with 85.43% working in polyvalent critical care units. Of the participants, 71% had access to EEG, of whom 40.17% could perform long-term cEEG monitoring, and 59.82% could perform only routine EEG. EEG monitoring was available 24/7 in 43%, Monday-Friday from 7am to 5 pm in 26%, and only in the mornings in 21% of whom had access to EEG. Remote neurotelemetry was only available to 15.96% of all respondents. Of all respondents, neurophysiologists executed the EEG report in the majority (35.9%), followed by neurologist non-neurophysiologist (19.7%) and by intensivists (7.4%). In some cases, the EEG was read by neurosurgeons or interns (10.1%). Conclusion: Our survey demonstrated limited access to cEEG in LA and a significant variability in the delivery of cEEG care in critically ill patients. Future research should focus on assessing the primary limitations of access to cEEG, aiming to provide improved standard patient care.

Systemic Metabolic Alterations after Aneurysmal Subarachnoid Hemorrhage

Oral Abstract Presenter: Aaron Gusdon, MD

Background: Aneurysmal rupture resulting in subarachnoid hemorrhage (aSAH) results in a robust systemic inflammatory response. We hypothesized that a shift in circulating metabolites with prominent changes in lipids would occur early after aSAH and predict outcomes. Methods: aSAH patients and controls were analyzed from two tertiary care centers (University of Texas Health Science Center and University of Maryland). Clinical data for all patients were abstracted including comorbidities as well as adjudicated outcomes such as occurrence of delayed cerebral ischemia (DCI) and modified Rankin Scale (mRS) score. Paired samples were collected within 24h and at 7d after aneurysm rupture. Mass spectrometry-based untargeted metabolomics was performed. A total of 1,370 metabolites were detected. Principal component analysis (PCA) was used to segregate controls from aSAH patients. Hierarchical clustering algorithms were developed to group sets of metabolites. Volcano plots were utilized to visualize fold changes for each metabolite relative to P-values comparing patients with or without DCI. Receiver operating curves (ROC) as well as multivariable logistic regression models were developed to assess utility of metabolites for predicting outcomes. Results: A total of 70 aSAH patients and 30 age matched controls were included. Metabolites readily distinguished control from aSAH patients in PCA analysis. Hierarchical clustering revealed significantly higher levels of free fatty acids in patients with aSAH but lower levels of acylcholines. Volcano plots demonstrated that in patients with DCI, sphingosine and sphinganine were significantly increased (fold change > 2, false discovery rate [FDR] corrected P-value < 0.1), while S-adenosylhomocysteine and two acylcarnitines were significantly decreased (fold change < -2, FDR corrected P-value < 0.1). Sphingosine had an AUC of 0.723 (95% CI 0.6001, 0.834) for predicting DCI. In multivariable regression models corrected for age, clinical severity, and sex, sphingosine [OR 10.2 (95%CI 2.46 ,59.8)] and sphinganine [OR 4.52 (95%CI 1.57, 20.9)] were associated with DCI. Levels of sphingosine 1-phosphate were higher in women with DCI but not men. Levels of the enzyme autotaxin, which can produce sphingosine 1-phosphate, were significantly higher in women than men (P=0.0045 among patients with DCI and P=0.0029 among patients without DCI). Conclusions: Plasma metabolites readily distinguish aSAH from controls. Increased circulating sphingosine and sphinganine were associated with DCI, while sphingosine 1-phosphate was increased in DCI only in women. Sex differences in enzymes involved in sphingolipid metabolism may contribute to risk of DCI after aSAH.