Clinical Variables and Neuromonitoring Information (Intracranial Pressure and Brain Tissue Oxygenation) as Predictors of Brain-Death Development After Severe Traumatic Brain Injury

doi:10.1016/j.transproceed.2012.07.070

Transplantation Proceedings

Volume 44, Issue 7, September 2012, Pages 2050-2052

https://doi.org/10.1016/j.transproceed.2012.07.070 Get rights and content

Abstract

Background and purpose

The aim of this study was to ascertain the role of clinical variables and neuromonitoring data as predictors of brain death (BD) after severe traumatic brain injury (TBI).

Patients and methods

This prospective observational study involved severe TBI patients admitted to the intensive care unit between October 2009 and May 2011. The following variables were recorded: gender, age, reference Glasgow Coma Scale after resuscitation, pupillary reactivity, prehospital hypotension and desaturation, injury severity score, computed tomography (CT) findings, intracranial hypertension, and low brain tissue oxygenation (Pti02) levels (<16 mm Hg), as well as the final result of BD.

Results

Among 61 patients (86.9% males) who met the inclusion criteria, the average age was 37.69 ± 16.44 years. Traffic accidents were the main cause of TBI (62.3%). The patients at risk of progressing to BD (14.8% of the entire cohort) were those with a mass lesion on CT (odds ratio [OR] 33.6; 95% confidence interval [CI]: 3.75–300.30; P = .002), altered pupillary reaction at admission (OR 25.5; 95% CI: 2.27–285.65; P = .009), as well low Pti02 levels on admission (OR 20.41; 95% CI: 3.52–118.33; P < .001) and during the first 24 hours of neuromonitoring (OR 20; 95% CI: 2.90–137.83; P < .001). Multivariate logistic regression showed that a low Pti02 level on admission was the best independent predictor for BD (OR 20.41; 95% CI: 3.53–118.33; P = .001).

Conclusions

Clinical variables and neuromonitoring information may identify TBI patients at risk of deterioration to BD.

Section snippets

Patients and Methods

This prospective observational study involved severe TBI patients who were defined as Glasgow Coma Scale score (GCS) ≤ 8 and admitted to our intensive care unit between October 2009 and May 2011. Our protocol was approved by the Institutional Review Board. Written consent was obtained from relatives for clinical data collection. We excluded patients with an injury severity score (ISS) of 75. The following variables were recorded: gender, age, reference GCS after resuscitation, papillary

Results

Among 61 severe TBI patients who met the inclusion criteria, the average age was 37.69 ± 16.44 years and 53 were males (62.20%). Traffic accidents were the main cause of TBI (62.3%). Prehospital hypotension and desaturation were detected in 18 patients (29.5%). Nine patients (14.8%) progressed to BD. All patients showed pathological computed tomography (CT) findings (none within TCDB category I); 43 showed a diffuse lesion (TCDB II–IV) and 18, a mass lesion (TCDB V–VI) on CT scan.

Clinical

Dicussion

Clinical variables suggest that TBI patients are at risk of deterioration to BD. Data from neuromonitoring techniques, such as brain tissue oxygenation, may lead to a positive selection of patients who are truly at risk. A recent study has proposed Pti02 as ancillary information to diagnose BD in children.⁸ To our knowledge, no study has been performed in adults using Pti02 as a predictor of BD.

Physicians and coordination teams could use clinical variables and neuromonitoring information to

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Cerebral microdialysis in the current clinical setting
Med Intensiva
(2012)
The global observatory on donation and transplantation
A.J. Marín-Caballos et al.
Cerebral perfusion pressure and risk of brain hypoxia in severe head injury: a prospective observational study
Crit Care
(2005)

There are more references available in the full text version of this article.

Cited by (21)

Donor referral from outside the intensive care unit: A multidisciplinary cooperation model using communication apps and redefining refereal criteria
2020, Medicina Intensiva
Citation Excerpt :
The implementation of a DCD program in 2015 allowed the wish to donate of those who did not progress to BD to be fulfilled. Criteria used to refer possible donors to DC should be regularly reviewed according to the clinical31 and neuromonitoring32,33 evidence available in order to fine tune their predictive power. The probability of not progressing to BD in possible donor candidates is a risk that should be taken into account and must be clearly transmitted to the patients’ relatives before ICU admission to facilitate donation.
We evaluate the impact of a web-based collaborative system on the referral of possible organ donors from outside of the intensive care unit (ICU).
Cohort prospective study.
University hospital.
In 2015 a virtual collaborative system using a cross-platform instant messaging application replaced the previous 2014 protocol for the referral of patients outside of the ICU with a severe brain injury in whom all treatment options were deemed futile by the attending team to the donor coordination (DC). Once the DC evaluated the medical suitability and likelihood of progression to brain death (BD), the option of intensive care to facilitate organ donation (ICOD) was offered to the patient's relatives. This included admission to the ICU and elective non-therapeutic ventilation (ENTV), where appropriate.
A two-fold increase of referrals was noted in 2015 [n = 46/74; (62%)] compared to 2014 [n = 13/40; (32%)]; p < 0.05. Patients were mostly referred from the stroke unit (58.6%) in 2015 and from the emergency department (69.2%) in 2014 (p < 0.01). Twenty (2015: 42.5%) and 4 (2014: 30.7%) patients were discarded as donors mostly due to medical unsuitability. Family accepted donation in 16 (2015: 62%) and 6 (2014: 66%) cases, all admitted to the ICU and 10 (2015: 62.5%) and 3 (50%) being subject to ENTV. Ten (2015: 66.6%) and 5 (2014: 83.3%) patients progressed to BD, 60.5 ± 20.2 and 44.4 ± 12.2 h after referral respectively. Nine (2015) and 4 (2014) of these patients became utilized donors, representing 29.0% (2015) and 13.0% (2014) of the BD donors in the hospital during the study period (p < 0.05).
The implementation of a virtual community doubled the number of patients whose families were presented with the option of donation prior to their death.
Evaluación del impacto de un sistema de colaboración por red en la detección de posibles donantes fuera de la unidad de cuidados intensivos (UCI).
Estudio prospectivo de cohortes.
Hospital universitario.
En 2015 se creó una comunidad virtual mediante mensajería multiplataforma que reemplazó al anterior sistema de notificación (2014) al coordinador de trasplantes (CT) de aquellos pacientes fuera de la UCI con lesiones neurológicas graves en los que el equipo tratante había considerado fútil cualquier opción terapéutica. Tras determinar la ausencia de contraindicaciones médicas y la probabilidad de progresión a muerte encefálica (ME) el CT ofrecía a los familiares la opción de cuidados intensivos orientados a la donación incluyendo el ingreso en la UCI y la ventilación electiva no terapéutica (VENT).
En 2015 (n = 46/74; 62%) se dobló el número de notificaciones con respecto a 2014 (n = 13/40; 32%); p < 0,05. Los pacientes procedían mayoritariamente de la unidad de ictus (2015: 58,6%) y urgencias (2014: 69,2%); p < 0,01. Un total de 20 (2015: 42,5%) y 4 (2014: 30,7%) pacientes se desestimaron como donantes por contraindicación médica. Los familiares aceptaron la donación en 16 (2015: 62%) y 6 (2014: 66%) casos; todos ingresaron en la UCI y 10 (2015: 62,5%) y 3 (50%) de ellos recibieron VENT. Diez (2015: 66,6%) y 5 (2014: 83,3%) pacientes progresaron a ME, 60,5 ± 20,2 y 44,4 ± 12,2 h después de su notificación, respectivamente. Nueve (2015) y 4 (2014) de estos pacientes fueron donantes utilizados, representando el 29,0% (2015) y el 13,0% (2014) de los donantes en ME (p < 0,05).
La implementación de una comunidad virtual duplicó el número de pacientes cuyas familias recibieron la opción de donación antes de su muerte.
Prognostic value of post-acute EEG in severe disorders of consciousness, using American Clinical Neurophysiology Society terminology
2019, Neurophysiologie Clinique
To evaluate whether electroencephalographic (EEG) features recorded during the post-acute stage in patients with severe disorders of consciousness (DoC) after acute brain injury (ABI), contribute to neurological outcome prediction of these patients at discharge from the intensive rehabilitation unit (IRU).
We retrospectively evaluated all patients consecutively admitted to the IRU from August 2012 to December 2016. Inclusion criteria were: 1) age > 18years, 2) patients with unresponsive wakefulness syndrome (UWS) or in a minimally conscious state (MCS), and 3) EEG and a coma recovery scale-revised (CRS-R) score available within the first week after admission. Clinical evaluation was performed using the Italian version of the CRS-R score. EEGs were classified according to American Clinical Neurophysiology Society (ACNS) terminology. Clinical state at final discharge was evaluated using the CRS-R score.
In total, 102 patients were included in the analysis. After a mean of five months of IRU stay, among the 61 UWS subjects, 19 transitioned to MCS and 11 recovered to exit-MCS (E-MCS); twenty-three of the 41 subjects in MCS progressed to E-MCS. Using logistic regression, consciousness level (UWS/MCS-OR = 13.4), CRS-R score at admission (OR = 1.33) and use of activating drugs (OR = 4.7) were significant predictors of clinical improvement. Multivariable analysis showed that specific EEG patterns were independent predictors of improved consciousness at discharge in UWS patients.
EEG performed within the first week after IRU admission, classified according to ACNS-terminology in patients with UWS at admission, can provide useful prognostic contribution.
Is brain computed tomography combined with somatosensory evoked potentials useful in the prediction of brain death after cardiac arrest?
2017, Neurophysiologie Clinique
Citation Excerpt :
Nevertheless, identifying patients with severe ABIs deteriorating toward BD is particularly difficult in the early acute phase because, to date, no accurate criteria for predicting evolution toward BD in comatose patients have been reported. A few prior studies have evaluated predictors of BD in patients with intracerebral hemorrhage (ICH), traumatic brain injury (TBI), and brain infarction [6,9,16,27]. Severe hypoxic ischemic encephalopathy (HIE) less frequently evolves toward BD compared to acute brain damage of different vascular and traumatic aetiologies [1,5,26,27].
Brain death (BD) in coma after cardiac arrest (CA) is difficult to predict. Basal ganglia gray matter/white matter (GM/WM) ratio density and somatosensory evoked potentials (SEPs) may differentiate patients evolving toward BD.
We used SEPs and brain computed tomography (CT) after coma onset, within the first 24 hours.
Of the 160 patients included in the study, 22 (14%) evolved toward BD. SEP patterns predicted BD (ROC area = 0.82, P < 0.0001). The combination of SEP patterns, bilaterally absent (AA) and absent on one hemisphere and pathological on the other (AP), predicted BD with a sensitivity of 100% and a specificity of 62.3%, with a positive likelihood ratio of 2.65. The GM/WM ratio predicted BD (ROC area = 0.68, P = 0.01). A GM/WM ratio < 1.07 had a sensitivity of 30.4%, a specificity of 94.9%, and a positive likelihood ratio of 6.27. The combination of SEP and CT findings did not increase the prediction of BD.
SEPs and brain CT within 24 hours predicted BD after CA. Severe SEP findings (SEP patterns: AA, AP) identified a subset of patients in whom BD could occur. Brain CT (GM/WM ratio in basal ganglia) predicted an early evolution toward BD with high specificity but lower sensitivity.
La mort cérébrale survenant dans le coma post arrêt cardio-respiratoire (ACR) est difficile à prédire. La densité de la substance grise et de la substance blanche (SG/SB) et les potentiels évoqués somesthésiques (PES) peuvent différencier les patients évoluant vers la mort cérébrale.
Nous avons étudié les PES et la tomodensitométrie cérébrale (TDMc) au cours des 24 premières heures après le début du coma post ACR. Nous avons mesuré le rapport SG/SB des ganglions de la base dans un groupe de 160 patients comateux post ACR en association avec l’enregistrement des PES.
Sur les 160 patients inclus dans l’étude, 22 (14 %) ont évolué vers mort cérébrale. Le profil des PES a prédit une mort cérébrale (aire ROC = 0,82, p < 0,0001). La combinaison des PES absents bilatéralement (AA) ou absents sur un hémisphère et pathologique sur l’autre (AP) a prédit la mort cérébrale avec une sensibilité de 100 % et une spécificité de 62,3 % avec un rapport de vraisemblance positif de 2,65. Le rapport SG/SB prédit mort cérébrale (aire ROC = 0,68, p = 0,01). Le rapport SG/SB < 1,07 présentait une sensibilité de 30,4 %, une spécificité de 94,9 % et un rapport de vraisemblance positif de 6,27. La combinaison des résultats de PES et de TDMc n’a pas augmenté la prédiction de la mort cérébrale.
Les PES et la TDMc prédisent la mort cérébrale dans les 24 heures après ACR. L’analyse des PES a permis l’identification d’un sous-groupe de patients à risque accru de progression vers la mort cérébrale. La TDMc cérébrale a permis de prédire une évolution précoce vers la mort cérébrale avec une spécificité élevée mais une moindre sensibilité.
Predictive patterns of sensory evoked potentials in comatose brain injured patients evolving to brain death
2017, Neurophysiologie Clinique
Citation Excerpt :
Fifth, we are aware that evolution towards BD is a multifactorial process and that patients’ comorbidities could affect this, but since we did not have complete medical histories we could analyse only age and sex. Sixth, even though we did not carry out a prognostic comparison of neuroradiological data, clinical signs (brainstem reflexes), ICP and brain tissue oxygenation, which have been previously evaluated in other studies [10,15,23], our main aim was to verify whether SEPs were a reliable prognostic indicator to include in future multivariate models. Last but not least, it was true that “self-fulfilling prophecies” might have affected the outcomes of patients with ABI [22]; however, do-not-resuscitate orders or decisions to withdraw life support are not included in our institutional standards of care.
To assess whether Somatosensory Evoked Potentials (SEPs), recorded within 24 h after ICU admission, are reliable predictors of brain death (BD) in comatose patients with acquired brain injury of various aetiologies.
SEPs were classified as absent (A), pathological (P), and normal (N). Considering SEP recordings from both hemispheres, 6 patterns were identified: NN, NP, PP, NA, AP, and AA. The final endpoint was BD.
Of the 203 patients included in the study, 70 (34%) evolved toward BD. The survival analysis indicated that the combination of SEP patterns in a two-graded scale (grade 1: NN-NP-PP-NA, and grade 2: AP-AA), allowed for prediction of BD with the best accuracy. This aggregation predicted BD with a sensitivity of 75.7% (CI: 64–84), a specificity of 76.6% (CI: 68–83), a positive predictive value of 64.2% (CI: 53–74) and a negative predictive value of 84.3% (CI: 77–90) in overall patients, and with a sensitivity of 75.0% (CI: 63–84), a specificity of 84.9% (CI: 75–90), a positive predictive value of 77.5% (CI: 63–88) and a negative predictive value of 84.3% (CI: 74–91) when excluding cardiac arrest.
It is worth including SEPs, in association with other investigations and clinical signs, in prognostic scores of BD. The early identification of patients at high risk of evolving towards BD could help physicians to optimise management.
Déterminer si les potentiels évoqués somesthésiques (PES), enregistrés dans les 24 h après l’admission en réanimation, sont des indicateurs fiables de la mort cérébrale chez les patients comateux avec des lésions cérébrales acquises de diverses étiologies.
Les PES ont été classés comme étant absent (A), pathologique (P), ou normal (N). Compte tenu des enregistrements effectués au niveau des deux hémisphères, 6 profils de résultat ont été identifiés : NN, NP, PP, AN, AP, et AA. Le critère d’évaluation finale était la mort cérébrale.
Sur les 203 patients inclus dans l’étude, 70 (34 %) ont évolué vers la mort cérébrale. L’analyse de survie a indiqué que la répartition des résultats en deux classes (classe 1 : profils NN, NP, PP, et NA, et classe 2 : AP et AA) permettait de prédire la mort cérébrale de façon optimale, avec une sensibilité de 75,7 % (intervalle de confiance : [64–84 %]), une spécificité de 76,6 % [68–83 %], une valeur prédictive positive de 64,2 % [53–74 %], et une valeur prédictive négative de 84,3 % [77–90 %] pour l’ensemble des patients. En excluant les arrêts cardiaques, la sensibilité était de 75,0 % [63–84 %], la spécificité de 84,9 % [75–90 %], la valeur prédictive positive de 77,5 % [63–88 %], et la valeur prédictive négative de 84,3 % [74–91 %].
Inclure les données de PES en association avec d’autres éléments cliniques ou paracliniques peut être utile pour établir un pronostic de mort cérébrale chez les patients en réanimation. L’identification précoce des patients à risque d’évoluer vers la mort cérébrale pourrait aider à optimiser les choix thérapeutiques dans ce contexte.
Usefulness of biomarkers in the prognosis of severe head injuries
2016, Medicina Intensiva
El traumatismo craneoencefálico grave es una entidad clínica con gran repercusión en términos socioeconómicos y de salud pública. Pese a los avances obtenidos en el ámbito del diagnóstico y tratamiento, no se han consolidado modelos predictivos suficientemente fiables que permitan desarrollar ensayos clínicos e impulsen estrategias terapéuticas efectivas que mejoren su pronóstico. En este sentido, durante las últimas décadas se han estudiado diversos biomarcadores de lesión cerebral con el fin de establecerlos como herramientas diagnósticas y pronósticas de la lesión traumática cerebral. Sin embargo, todos ellos presentan alguna limitación que impide su aplicación universalizada. Es necesario analizar las propiedades de los biomarcadores conocidos hasta la fecha, tanto los que tradicionalmente han demostrado correlación con la gravedad y pronóstico como aquellos que recientemente se anuncian prometedores. Para ello, convendría diseñar nuevos estudios que definan sus propiedades de forma aislada y que diluciden el papel de su uso combinado.
Severe head injuries have a great socioeconomic and public health impact. Despite progress in diagnosis and treatment, no sufficiently reliable predictive models have been established for developing clinical trials and promoting effective therapeutic strategies capable of improving the prognosis. In the last decades, several brain damage biomarkers have been studied as potential diagnostic and prognostic tools in traumatic brain injury. However, all of them have limitations that preclude their universalized application. The properties of the known biomarkers –both those traditionally shown to correlate with severity and prognosis, and those recently announced as promising options– should be analyzed. New studies are needed to define their properties, both isolatedly and in combined use.
Diagrams to interpret and solve physiopathological events triggered after severe traumatic brain injury
2015, Medicina Intensiva

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Organ donationClinical Variables and Neuromonitoring Information (Intracranial Pressure and Brain Tissue Oxygenation) as Predictors of Brain-Death Development After Severe Traumatic Brain Injury

Abstract

Background and purpose

Patients and methods

Results

Conclusions

Section snippets

Patients and Methods

Results

Dicussion

Med Intensiva

The global observatory on donation and transplantation

Cerebral perfusion pressure and risk of brain hypoxia in severe head injury: a prospective observational study

Crit Care

Organ donation
Clinical Variables and Neuromonitoring Information (Intracranial Pressure and Brain Tissue Oxygenation) as Predictors of Brain-Death Development After Severe Traumatic Brain Injury