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>
	<li>Jones, P. A., 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=Measuring+the+burden+of+secondary+insults+in+head-injured+patients+during+intensive+care.">Measuring the burden of secondary insults in head-injured patients during intensive care.</a> Journal of Neurosurgical Anesthesiology. 6 (1), 4-14 (1994).</li><li>Juul, N., Morris, G. F., Marshall, S. B., Marshall, L. F. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Intracranial+hypertension+and+cerebral+perfusion+pressure:+influence+on+neurological+deterioration+and+outcome+in+severe+head+injury.+The+Executive+Committee+of+the+International+Selfotel+Trial.">Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. 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. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemorrhagic+complications+of+ventriculostomy+placement:+a+meta-analysis.">Hemorrhagic complications of ventriculostomy placement: a meta-analysis.</a> Neurocritical Care. 10 (2), 253-256 (2009).</li><li>Bauer, D. F., Razdan, S. N., Bartolucci, A. A., Markert, J. M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Meta-analysis+of+hemorrhagic+complications+from+ventriculostomy+placement+by+neurosurgeons.">Meta-analysis of hemorrhagic complications from ventriculostomy placement by neurosurgeons.</a> Neurosurgery. 69 (2), 255-260 (2011).</li><li>Poca, M. -. A., Sahuquillo, J., Arribas, M., B&#225;guena, M., Amor&#243;s, S., Rubio, E. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Fiberoptic+intraparenchymal+brain+pressure+monitoring+with+the+Camino+V420+monitor:+reflections+on+our+experience+in+163+severely+head-injured+patients.">Fiberoptic intraparenchymal brain pressure monitoring with the Camino V420 monitor: reflections on our experience in 163 severely head-injured patients.</a> Journal of Neurotrauma. 19 (4), 439-448 (2002).</li><li>Koskinen, L. -. O. D., Grayson, D., Olivecrona, M. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=The+complications+and+the+position+of+the+Codman+MicroSensorTM+ICP+device:+an+analysis+of+549+patients+and+650+Sensors.">The complications and the position of the Codman MicroSensorTM ICP device: an analysis of 549 patients and 650 Sensors.</a> Acta Neurochirurgica. 155 (11), 2141-2148 (2013).</li><li>Badri, S., 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=Mortality+and+long-term+functional+outcome+associated+with+intracranial+pressure+after+traumatic+brain+injury.">Mortality and long-term functional outcome associated with intracranial pressure after traumatic brain injury.</a> Intensive Care Medicine. 38 (11), 1800-1809 (2012).</li><li>Yuan, Q., 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=Impact+of+intracranial+pressure+monitoring+on+mortality+in+patients+with+traumatic+brain+injury:+a+systematic+review+and+meta-analysis.">Impact of intracranial pressure monitoring on mortality in patients with traumatic brain injury: a systematic review and meta-analysis.</a> Journal of Neurosurgery. 122 (3), 574-587 (2015).</li><li>Shen, L., 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=Effects+of+Intracranial+Pressure+Monitoring+on+Mortality+in+Patients+with+Severe+Traumatic+Brain+Injury:+A+Meta-Analysis.">Effects of Intracranial Pressure Monitoring on Mortality in Patients with Severe Traumatic Brain Injury: A Meta-Analysis.</a> PloS One. 11 (12), e0168901 (2016).</li><li>Chesnut, R. M., 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=A+trial+of+intracranial-pressure+monitoring+in+traumatic+brain+injury.">A trial of intracranial-pressure monitoring in traumatic brain injury.</a> The New England Journal of Medicine. 367 (26), 2471-2481 (2012).</li><li>Aries, M. J. H., 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=Continuous+determination+of+optimal+cerebral+perfusion+pressure+in+traumatic+brain+injury.">Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury.</a> Critical Care Medicine. 40 (8), 2456-2463 (2012).</li><li>Vespa, P., 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=Metabolic+crisis+occurs+with+seizures+and+periodic+discharges+after+brain+trauma.">Metabolic crisis occurs with seizures and periodic discharges after brain trauma.</a> Annals of Neurology. 79 (4), 579-590 (2016).</li><li>Hartings, J. A., 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=Spreading+depolarisations+and+outcome+after+traumatic+brain+injury:+a+prospective+observational+study.">Spreading depolarisations and outcome after traumatic brain injury: a prospective observational study.</a> The Lancet. Neurology. 10 (12), 1058-1064 (2011).</li><li>Okonkwo, D. O., 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=Brain+Oxygen+Optimization+in+Severe+Traumatic+Brain+Injury+Phase-II:+A+Phase+II+Randomized+Trial.">Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: A Phase II Randomized Trial.</a> Critical Care Medicine. 45 (11), 1907-1914 (2017).</li><li>Foreman, B., Ngwenya, L. B., Stoddard, E., Hinzman, J. M., Andaluz, N., Hartings, J. A. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Safety+and+Reliability+of+Bedside,+Single+Burr+Hole+Technique+for+Intracranial+Multimodality+Monitoring+in+Severe+Traumatic+Brain+Injury.">Safety and Reliability of Bedside, Single Burr Hole Technique for Intracranial Multimodality Monitoring in Severe Traumatic Brain Injury.</a> Neurocritical Care. , (2018).</li><li>Stuart, R. M., 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=Intracranial+multimodal+monitoring+for+acute+brain+injury:+a+single+institution+review+of+current+practices.">Intracranial multimodal monitoring for acute brain injury: a single institution review of current practices.</a> Neurocritical Care. 12 (2), 188-198 (2010).</li><li>Talving, P., 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=Intracranial+pressure+monitoring+in+severe+head+injury:+compliance+with+Brain+Trauma+Foundation+guidelines+and+effect+on+outcomes:+a+prospective+study.">Intracranial pressure monitoring in severe head injury: compliance with Brain Trauma Foundation guidelines and effect on outcomes: a prospective study.</a> Journal of Neurosurgery. 119 (5), 1248-1254 (2013).</li><li>Aiolfi, A., Benjamin, E., Khor, D., Inaba, K., Lam, L., Demetriades, D. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Brain+Trauma+Foundation+Guidelines+for+Intracranial+Pressure+Monitoring:+Compliance+and+Effect+on+Outcome.">Brain Trauma Foundation Guidelines for Intracranial Pressure Monitoring: Compliance and Effect on Outcome.</a> World Journal of Surgery. 41 (6), 1543-1549 (2017).</li><li>Pinggera, D., Petr, O., Putzer, G., Thom&#233;, C. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=How+I+do+it/Technical+note:+Adjustable+and+Rigid+Fixation+of+Brain+Tissue+Oxygenation+Probe+(LICOX)+in+Neurosurgery+-+from+bench+to+bedside.">How I do it/Technical note: Adjustable and Rigid Fixation of Brain Tissue Oxygenation Probe (LICOX) in Neurosurgery - from bench to bedside.</a> World Neurosurgery. 117, 62-64 (2018).</li><li>Gardner, P. A., Engh, J., Atteberry, D., Moossy, J. J. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemorrhage+rates+after+external+ventricular+drain+placement.">Hemorrhage rates after external ventricular drain placement.</a> Journal of Neurosurgery. 110 (5), 1021-1025 (2009).</li><li>Maniker, A. H., Vaynman, A. Y., Karimi, R. J., Sabit, A. O., Holland, B. <a target="_blank" href="http://www.ncbi.nlm.nih.gov/entrez/query.fcgi?db=PubMed&cmd=Search&doptcmdl=Citation&defaultField=Title+Word&term=Hemorrhagic+complications+of+external+ventricular+drainage.">Hemorrhagic complications of external ventricular drainage.</a> Neurosurgery. 59 (4 Suppl 2), (2006).</li><li>Dreier, J. P., 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=Recording,+analysis,+and+interpretation+of+spreading+depolarizations+in+neurointensive+care:+Review+and+recommendations+of+the+COSBID+research+group.">Recording, analysis, and interpretation of spreading depolarizations in neurointensive care: Review and recommendations of the COSBID research group.</a> Journal of Cerebral Blood Flow and Metabolism: Official Journal of the International Society of Cerebral Blood Flow and Metabolism. 37 (5), 1595-1625 (2017).</li></ol>

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 ...

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