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

Summary

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

Abstract

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.

Introduction

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'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, elevat....

Protocol

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’s Institutional Review Board.

1. Patient Selection

1. 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 acute brain injury processes warrant monitoring.
   1. Rule out confounders that may cloud clinical examination including elevated alcohol level or ....

Results

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.

Discussion

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.......

Materials

List of materials used in this article

Name	Company	Catalog Number	Comments
Cranial Access Kit	Natus Medical Inc.	NA	Cranial Access kit
Neurovent PTO	Qflow 500	NA	ICP/PBtO2 catheter
Qflow 500 Perfusion Probe	Hemedex, Inc	#H0000-1600	rCBF catheter
Qflow 500 Titanium Bolt	Hemedex, Inc	#H0000-3644	Cranial access bolt
Spencer Depth Electrode	Ad-Tech Medical Instrument Corporation	NA	iEEG