Head injury monitoring using cerebral microdialysis and Paratrend multiparameter sensors

Summary:

Introduction: Following head injury complex pathophysiological changes occur in brain metabolism. The objective of the study was to monitor brain metabolism using the Paratrend multiparameter sensor and microdialysis catheters. Patients, material and methods: Following approval by the Local Ethics Committee and consent from the relatives, patients with severe head injury were studied using a triple bolt inserted into the frontal region, transmitting an intracranial pressure monitor, microdialysis (10 mm or 30 mm membrane; glucose, lactate, pyruvate, glutamate) catheter and Paratrend multiparameter (oxygen, carbon dioxide, pH and temperature) sensor. A Paratrend sensor was also inserted into the femoral artery for continuous blood gas analysis. Results: 21 patients were studied with cerebral microdialysis for a total of 91 monitoring days (range 19 hours to 12 days). Of these, 14 patients were also studied with cerebral and arterial Paratrend sensors. The mean (± 95% confidence intervals) arterial and cerebral oxygen levels were 123 ± 10.9 mmHg and 27.9 ± 5.71 mmHg respectively. The arterial and cerebral carbon dioxide levels were 34.3 ± 2.35 mmHg and 45.3 ± 3.07 mmHg respectively. Episodes of systemic hypoxia and hypotension resulting in falls in cerebral oxygen and rises in cerebral carbon dioxide were rapidly detected by the arterial and cerebral Paratrend sensors. Systemic pyrexia was reflected in the brain with the cerebral Paratrend sensor reading 0.17 °C (mean) higher than the arterial sensor. Elevations of cerebral glucose were detected, but the overall cerebral glucose was low (mean 1.57 ± 0.53 mM 10 mm membrane; mean 1.95 ± 0.68 mM 30 mm membrane) with periods of undetectable glucose in 6 patients. Lactate concentrations (mean 5.08 ± 0.73 mM 10 mm membrane; mean 8.27 ± 1.31 mM 30 mm membrane) were higher than glucose concentrations in all patients. The lactate/pyruvate ratio was 32.1 ± 5.16 for the 10 mm membrane and 30.6 ± 2.17 for the 30 mm membrane. Glutamate concentrations varied between patients (mean 15.0 ± 10.5 μM 10 mm membrane; mean 28.8 ± 17.8 μM 30 mm membrane). Conclusion: The combination of microdialysis catheters and Paratrend sensors enabling the monitoring of substrate delivery and brain metabolism, and the detection of secondary metabolic insults has the potential to assist in the management of head-injured patients.

Key words:

Brain metabolism - trauma - multimodality monitoring - monitoring probes

References

• 1 Benveniste H. Brain microdialysis.  J Neurochem. 1989;  52 1667-1679
• 2 Bullock R, Zauner A, Tsuji O. et al. .Excitatory amino acid release after severe human head trauma: effect of intracranial pressure and cerebral perfusion pressure changes. In: Nagai H, Kamiya K, Ishii S (Eds). Intracranial pressure IX. Springer, Tokyo 1994: 264-267
• 3 Chesnut R M, Marshall D B, Piek J. et al. . Early and late systemic hypotension as a frequent and fundamental source of cerebral ischaemia following severe brain injury in the Traumatic Coma Data Bank.  Acta Neurochir Wien. 1993;  59 ((Suppl)) 121-125
• 4 During M J, Spencer D D. Extracellular hippocampal glutamate and spontaneous seizure in the conscious human brain.  Lancet. 1993;  341 1607-1610
• 5 Editorial: Microdialysis.  Lancet. 1992;  339 1326-1327
• 6 Fernandez R, Firsching R, Lobato R. et al. . Guidelines for treatment of head injury in adults. Opinions of a group of neurosurgeons.  Zentralbl Neurochir. 1997;  58 72-74
• 7 Goodman J C, Gopinath S P, Valadka A B. et al. . Lactic acid and amino acid fluctuations measured using microdialysis reflect physiological derangements in head injury.  Acta Neurochir Wien. 1996;  67 (Suppl) 37-39
• 8 Hillered L, Valtysson J, Enblad P. et al. . Interstitial glycerol as a marker for membrane phospholipid degradation in the acutely injured human brain.  J Neurol Neurosurg Psychiatry. 1998;  64 486-491
• 9 Hoffman W E, Charbel F T, Edelman G. et al. . Brain tissue oxygen pressure, carbon dioxide pressure and pH during ischemia.  Neurol Res. 1996;  18 54-56
• 10 Hutchinson P JA, Al-Rawi P G, O'Connell M T. et al. . On-line bedside monitoring of brain oxygen, glucose, lactate, pyruvate and glutamate in head injury: detection of secondary insults.  Br J Neurosurg. 1999;  13 531P
• 11 Jennett B, Bond M. Assessment of outcome after severe brain damage. A practical scale.  Lancet. 1975;  I 480-484
• 12 Kiening K L, Unterberg A W, Bardt T F. et al. . Monitoring of cerebral oxygenation in patients with severe head injuries: brain tissue pO₂ versus jugular vein oxygen saturation.  J Neurosurg. 1996;  85 751-757
• 13 Kirkpatrick P J, Czosnyka M, Pickard J D. Multimodality monitoring in neurointensive care.  J Neurol Neurosurg Psychiatry. 1996;  60 131-139
• 14 Kirkpatrick P J, Smielewski P, Czosnyka M. et al. . Near-infrared spectroscopy use in patients with head injury.  J Neurosurg. 1995;  83 963-970
• 15 Maas A IR, Dearden M, Teasdale G M. et al. . EBIC-Guidelines for management of severe head injury in adults.  Acta Neurochir. 1997;  139 286-294
• 16 Marmarou A, Anderson R L, Ward J D. et al. . Impact of ICP instability and hypotension on outcome in patients with severe head trauma.  J Neurosurg. 1991;  75 S59-S66
• 17 Meixensberger J, Dings J, Kuhnigk H. et al. . Studies of tissue pO₂ in normal and pathological human brain cortex.  Acta Neurochir Wien. 1993;  59 (Suppl) 58-63
• 18 Persson L, Hillered L. Chemical monitoring of neurosurgical intensive care patients using intracerebral microdialysis.  J Neurosurg. 1992;  76 72-80
• 19 Persson L, Valtysson J, Enblad P. et al. . Neurochemical monitoring using intracerebral microdialysis in patients with subarachnoid haemorrhage.  J Neurosurg. 1996;  84 606-616
• 20 Robertson C S, Gopinath S P, Goodman J C. et al. . SjvO₂ monitoring in head-injured patients.  J Neurotrauma. 1995;  12 891-896
• 21 Saveland H, Nilsson O G, Boris-Moller F. et al. . Intracerebral microdialysis of glutamate and aspartate in two vascular territories after aneurysmal subarachnoid haemorrhage.  Neurosurgery. 1996;  38 12-20
• 22 Smielewski P, Czosnyka M, Kirkpatrick P J. et al. . Evaluation of the transient hyperaemic response test in head-injured patients.  J Neurosurg. 1997;  86 773-778
• 23 Ungerstedt U. Introduction to intracerebral microdialysis. In: Robinson TE, Justice JB (Eds). Microdialysis in the Neurosciences. Elsevier, Amsterdam 1991: 3-43
• 24 Ungerstedt U. Microdialysis-principles and applications for studies in animals and man.  J Intern Med. 1991;  230 365-373
• 25 Unterberg A. European guidelines for treatment of increased intracranial pressure. European Brain Injury Consortium.  Zentralbl Neurochir. 1997;  58 143-144
• 26 van Santbrink H V, Maas A IR, Avezaat C JJ. Continuous monitoring of partial pressure of brain tissue oxygen in patients with severe head injury.  Neurosurgery. 1996;  38 21-31
• 27 Venkatesh B, Clutton-Brock T H, Hendry S P. A multi-parameter sensor for continuous intra-arterial blood gas monitoring: A prospective evaluation.  Crit Care Med. 1997;  22 588-594
• 28 Whittle I R. Intracerebral microdialysis: a new method in applied clinical neuroscience research.  Br J Neurosurg. 1990;  4 459-462
• 29 Zauner A, Doppenberg E, Woodward J J. et al. . Multiparametric continuous monitoring of brain metabolism and substrate delivery in neurosurgical patients.  Neurol Res. 1997;  19 265-273
• 30 Zauner A, Doppenberg E M, Woodward J J. et al. . Continuous monitoring of cerebral substrate delivery and clearance: initial experience in 24 patients with severe acute brain injuries.  Neurosurgery. 1997;  41 1082-1093