Name: a bedside, single burr hole approach to multimodality monitoring in severe brain injury
Uploaded: 2019-03-26T12:30:00
Description: Watch this Scientific Journal Video about A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury at JoVE.com

The authors wish to acknowledge the leadership of Dr. Norberto Andaluz (University of Louisville) for his role in spearheading this technique. We also wish to acknowledge the hard work of the neurosurgical residents who refined the technique and the neurocritical care nursing staff who have embraced this new technique for the benefit of their patients.

This protocol was developed as a standard of care. The retrospective use of data gathered during the course of care was approved through a waiver of informed consent by the University of Cincinnati&#8217;s Institutional Review Board.
1. Patient Selection
<ol>
	<li>Identify patient with acute brain injury (traumatic brain injury, stroke). 
	NOTE: Collaborative discussion between surgical and intensive care teams is critical to ensure that there is consensus on which acut...

<ol>
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The Executive Committee of the International Selfotel Trial.</a> Journal of Neurosurgery. 92 (1), 1-6 (2000).</li><li>Carney, N., et al. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Guidelines+for+the+Management+of+Severe+Traumatic+Brain+Injury,+Fourth+Edition.">Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition.</a> Neurosurgery. 80 (1), 6-15 (2017).</li><li>Hawthorne, C., Piper, I. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Monitoring+of+intracranial+pressure+in+patients+with+traumatic+brain+injury.">Monitoring of intracranial pressure in patients with traumatic brain injury.</a> Frontiers in Neurology. 5, 121 (2014).</li><li>Binz, D. D., Toussaint, L. G., Friedman, J. 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This article provides the practical elements of a method for introducing multiple probes into the brain follow acute brain injury in order to facilitate a multimodal approach to understanding the physiology underlying secondary brain injury. The existing Brain Trauma Foundation guidelines suggest the use of intracranial pressure monitoring in specific patients after trauma (Level IIb)3, although there is evidence to suggest that this is variably practiced even at high-volume level I trauma centers...

Severe brain injuries such as traumatic brain injury (TBI) or subarachnoid hemorrhage may result in coma, a clinical state in which patients do not respond to their environment. Neurosurgeons and neurointensivists rely heavily on the clinical neurological exam, but severe brain injuries may make it impossible to detect changes related to the brain&#39;s physiologic environment: elevations in intracranial pressure (ICP), decreases in cerebral blood flow, or nonconvulsive seizures and spreading depolarizations. These physiologic disturbances can lead to further injury, termed secondary brain injury.
After severe traumatic brain injury, elevations in ICP are common and may result in decreased blood flow and therefore secondary brain injury and neurodeterioration. Elevations in ICP have been documented in up to 89% of patients1 and neurodeterioration occurs in one-quarter, increasing mortality from 9.6% to 56.4%2. Therefore, the measurement of ICP is the most commonly used biomarker for the development of secondary brain injury and has a Level IIb recommendation from the Brain Trauma Foundation3.
The measurement of ICP was pioneered over 50 years ago4 using catheters that were introduced through a twist drill craniostomy (often referred to interchangeably as a burr hole) typically created in the frontal bone at the mid-pupillary line just anterior to the coronal suture and passed into the ventricles. However, these external ventricular drainage catheters (EVDs) require midline anatomy, which is not always present after severe brain injuries, and misplacement can potentially damage deep structures such as the thalamus. Although EVDs allow drainage of CSF as a potential treatment option, the hemorrhage rates from EVDs are 6&#8211;7% on average5,6.
Intraparenchymal pressure monitors are introduced via burr hole and are common alternatives and adjuncts to EVDs with hemorrhage rates of 3&#8211;5%7,8. These are smaller probes that sit 2&#8211;3 cm under the inner table of the skull, and allow for continuous measurement of pressure but without an option to drain cerebrospinal fluid, as do EVDs. Existing cohort studies9 and meta-analyses10,11 suggest that targeting ICP as a marker of secondary brain injury may improve survival; however, a randomized controlled trial comparing treatment of ICP based on neurological exam alone vs. measured ICP failed to demonstrate benefit12.
Advances in neurosurgery and neurointensive care have led to an understanding that brain physiology is more complicated than ICP alone. It has been demonstrated that autoregulatory function within the brain is impaired after brain injury13, leading to changes in the regulation of regional cerebral blood flow (rCBF). Further, the burden of nonconvulsive seizures14 and spreading depolarizations15 are being recognized using recordings from intracranial electroencephalography (iEEG) electrodes. Strategies to improve brain tissue oxygen (PbtO2) were shown to be a target for therapy and proved feasible in a large, multicenter Phase II clinical trial16.
This article describes a technique that allows for the simultaneous measurement of multiple modalities &#8212; including ICP, PbtO2, rCBF, and iEEG &#8212; using a simple, single burr hole placed at the bedside in patients with severe acute brain injuries requiring intensive care. Patient selection and surgical approach to this technique are included. This technique specifically allows for the placement of multiple probes to provide targeted monitoring of multiple physiologic parameters that may provide a more sensitive and specific early warning system for secondary brain injuries.

<table>
	<tbody>
		<tr>
			<td>Cranial Access Kit</td>
			<td>Integra LifeSciences</td>
			<td>NA</td>
			<td>Cranial Access kit</td>
		</tr>
		<tr>
			<td>Neurovent PTO</td>
			<td>Qflow 500</td>
			<td>NA</td>
			<td>ICP/PBtO2 catheter</td>
		</tr>
		<tr>
			<td>Qflow 500 Perfusion Probe</td>
			<td>Hemedex, Inc</td>
			<td>#H0000-1600</td>
			<td>rCBF catheter</td>
		</tr>
		<tr>
			<td>Qflow 500 Titanium Bolt</td>
			<td>Hemedex, Inc</td>
			<td>#H0000-3644</td>
			<td>Cranial access bolt</td>
		</tr>
		<tr>
			<td>Spencer Depth Electrode</td>
			<td>Ad-Tech Medical Instrument Corporation</td>
			<td>NA</td>
			<td>iEEG</td>
		</tr>
	</tbody>
</table>

a bedside, single burr hole approach to multimodality monitoring in severe brain injury

Intracranial pressure (ICP) monitoring is a cornerstone of the intensive care management of patients with severe acute brain injuries, including traumatic brain injury. While elevations in ICP are common, data regarding the measurement and treatment of these ICP elevations are conflicting. There is increasing recognition that changes in the balance between supply and demand of brain tissue are critically important and therefore the measurement of multiple modalities is required. Approaches are not standard, and therefore this article provides a description of a bedside, single burr hole approach to multimodality monitoring that allows the passage of probes designed to measure not only ICP but brain tissue oxygen, blood flow, and intracranial electroencephalography. Patient selection criteria, operative procedures, and practical considerations for securing probes during critical care are described. This method is readily performed, safe, secure, and flexible for the adoption of a variety of multimodality monitoring approaches aimed at detecting or preventing secondary brain injuries.

Experience in using this approach in 43 patients with severe TBI was recently published17. Patient selection limits the number of those eligible, but focusing on only those with TBI at a level I trauma center led to approximately 2 patients per month. This number is predicated on hospital volume and may increase if additional acute brain injuries are considered for monitoring, such as those with hemorrhagic stroke.
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Watch this Scientific Journal Video about A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury at JoVE.com

A Bedside, Single Burr Hole Approach to Multimodality Monitoring in Severe Brain Injury

A method of recording multimodality monitoring signals in patients with severe brain injuries using a bedside, single burr hole technique is described.

Intracranial pressure (ICP) monitoring is a cornerstone of the intensive care management of patients with severe acute brain injuries, including traumatic ...

The placement of a quad lumen monitor can allow for the collection of different types of data including intracranial pressure, brain tissue oxygenation, cerebral blood flow, and electrical activity. Our protocol allows different types of information to be collected in severe traumatic brain injury patients at the bedside using a simple procedure involving a single burr hole. Immobilize the head securely to ensure that it does not move during burr hole placement.Rolled towels and tape can be used to help secure the patient's head. Begin by identifying the correct location for the bolt placement. 11 centimeters from the nasion or one centimeter anterior to the coronal suture, and two to three centimeters laterally at about the mid-pupillary line.Sterilize the area with Betadine solution and use 1%lidocaine with epinephrine for local analgesia. While the Betadine is drying, thread each probe through a locking nut, and subsequently insert each probe through one of the lumens of the bolt. Place the intracranial pressure brain tissue oxygen probe preferentially in the tallest lumen.The other probes can be fit through any of the remaining lumens. Confirm that the distance from the end of the bolt to the tip of each probe is two and a half to three centimeters, and advance the depth electrode until the most proximal electrode is just outside the end of the bolt. Once the probe has been placed the appropriate distance from the end of the bolt, tighten the locking nut on the lumen of the bolt, and then on the probe itself to lock the probe in place.Then loosen the nut from the lumen and remove each probe with its locking nut in place, placing each probe on the sterile table next to the bolt. When all of the probes are ready, use a scalpel to make a one to two centimeter incision in the marked region, and use a blunt tipped instrument to separate the subgaleal tissues to expose the periosteum. Use a hex bit to tighten a 5.3 millimeter drill bit to the cranial drill, and place the drill perpendicular to the skull.Using continuous pressure while rotating the instrument, drill until there is a tactile change in pressure, and continue drilling with counter upward support to avoid plunging the drill into the cortex. Remove the drill and clear the burr hole of any bone chips or debris. Use a scalpel to incise the dura in a cruciate fashion and confirm that the dura is completely open.To insert the cranial bolt, hold the bolt by the plastic wings and thread the bolt through the burr hole with a firm clockwise twisting motion. Insert the thinnest pre-measured probe until the locking nut meets the lumen, followed by the rest of the probes. Insert the depth electrode with the stylet in place, and tighten the electrode on the lumen.Then gently loosen the locking nut from the probe, just enough to remove the stylet, before re-tightening the nut. When all of the probes have been inserted, have available personnel connect the intracranial pressure brain tissue oxygen probe to the bedside monitor, to assess the intracranial pressure and brain tissue oxygen. Then use durable tape to gently loop each probe to secure it to its lumen to create strain resistance.If desired, wrap the probes and bolt with sterile gauze at the completion of the procedure. All probes project through the bolt into the brain parenchyma within millimeters of each other. Here, scout computed tomography, or CT coronal and sagittal images, demonstrating the trajectory of probes at approximately 1.5 and two to three centimeters respectively below the inner table of the skull are shown.In this axial CT image, a probe placed after non-surgical severe traumatic brain injury with excellent placement can be observed. Note that with standard windowing, relatively dense probes may obscure subtle peri-probe hematomas. This axial CT image of a probe placed after surgical severe traumatic brain injury illustrates the location of a bolt and probes contralateral to the hemicraniectomy site.These incorrectly placed probes after non-surgical severe traumatic brain injury are approaching the frontal horn of the lateral ventricle, indicating that they are greater than three centimeters below the inner table of the skull, which may affect measurements obtained by the probes. Place the probes at the proper depth from the bottom of the bolt and tighten the locking nuts tightly enough that the probes do not get dislodged without becoming damaged. If intracranial pressures are high and refractory to treatment, an external ventricular drain can also be placed to drain cerebrospinal fluid and relieve intracranial pressure.A continuous scalp electroencephalography electrode can be placed to correlate potential seizure activity with the depth electrode findings.

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