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Noninvasive multimodal cerebral monitoring of head-injured patients in ICU
Monday. 7 July 1997 the p(ti)02-cathetercould not be insertedvia the introducer, makingit necessary to use a new introducer. sensitivity: Mean sensitivity was -9.5 ± 8.7% (7.6 ± 3.4 days, n- = 80). Cathetersremoved after less than 5 daysshoweda greaterdrift (-11.8 ± 5.4%, n = 22) compared to those removed after 5 days (- 6.5 ± 4.3%, n = 58); so, during the first 5 days of monitoring, a slight underestimation of the p(ti)~ can occur. Comparing initial cathetercharges to the latest, a clear quality-improvement can be shown (- 12.5 ± 6.5%, n = 26 to - 7.8 ± 3.3%, n = 54). Meanzero-driftwas 1.4 ± 1.5 mm Hg (n = 78); highest drift is seen after 5 days (2.0 ± 1.8 mm Hg, n 57). Conclusion: Brain tissue p02 monitoring is a practicable, safe and reliable monitoring method. reflectingchangesof cerebral microcirculation/oxygenation.
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IP-2-14SI Noninvasive multimodal cerebral monitoring of head-injured patients in ICU V. Amcheslavski, G. Toma, G. Margishvili. S.V. Madorski, A. Parfenov, E. Gaitur, A. Ostrovski. Burdenko Neurosurgicallnstitut. Moscow. Russia Introduction: One of the goals of noninvasive multimodal cerebral monitoring (NMCM)in critically ill patientswith severe head injury (HI) is the earlydetection and prevention of secondarybrain damagedue to ischemia. Methods: NMCM was used in 21 patients with severe HI. We preferred the bedside and non-invasive methods: 1) TCD for measurement of CBF velocity (Transpect Medasonics, Germany; Sonas2500 HP, USA); 2) NIRS(Cerebral OximeterInvos3100 Somanetics, USA) for investigation of cerebral oxygenation (CO); 3) registration of SSEP (Phasis, ESAOTE Biomedica, Italy) that provide definiteinformation on theintegrity of neuralpathways. This combinationof methods in addition to detailed neurological examination allowed us to receive more complete infonmation about functional, anatomical and metabolicstateof brain. Results: The patients were divided into 3 groups according to Gas. 1stpatients with fatal outcome(4); 2nd - patients with severe disability or vegetative state (6); 3rd - patients with good recovery or moderate disability (11). In the 1-st group high values of CBF velocity (227 ± 7 sm/sec) in both artery cerebri media, bilateral absence of SSEP, bilateral changes of CO unresponsive to therapeutic measures were revealed. In the 2-nd group -high values of CBF velocity (211 ± 15 sm/sec), predominantly on one side, with the peak on the 11·th day were observed. CBF velocity came to normal values 17-21 days after HI. Disturbancesof CO were revealed on the side of vasospasm and came to nonmal values 7- 14 days after HI. Disturbancesof SSEPwere asymmetric and persistent with improvement of SSEP in 2 cases. In the 3-rd group -moderate bilateral increase of CBF velocity (140 ± 8 sm/sec). normal values of CO, asymmetrical mild and reversible changes of SSEP were observed. Conclusion: NMCM can be useful for predicting the prognosis for recovery after HI. This combination of methods allowed assessment of the integrity of the brain during critical period in HI.
I P-2-149I Multi evoked potential study and CT scan in patients with brain contusion S. Djuric' , Z. Milenkovie2 , M. Jolie 1 , A. llie 1, I. Stefanovie 2 , J. stamenovlc 1. of Neurology, Clinical Centre. Nis, Yugoslavia. 2 Department of Neurosurgery, Clinical Centre. Nis. Yugoslavia
1 Department
Multi·evoked potentials (MEPs) are recognized as a useful technique in clinical neurophysiology and have also been advocatedas a sensitive measure in brain contusion. in order to detect an abnormal function of the peripheral and central nervous system. All patients (32) with braincontusion underwentneurological, neuroradtoloqical (CT·scan) and neurophysiological evaluations in the threedays after injury. Neurophysiological parameters were analysed as well as the relationships with clinical and neuroradiological findings. Abnormal function of brain by MEPswas observed in 28 patients (87.5%) and neuroradiological findings were abnormal in 19 patients (59.4%). Our results show high diagnostic sensitivity of MEPs, while there was no correlation with neuroradiological parameters.
IP-2-150 I Short of ~rainstem audltory evoked potentials in coma patients M. Jolie 1 , S. Djurie 1 , G. IgnjatoviC 2, I. Statanovic 2, M. Lazarevic 1 , J. Starnenovic 1 , S. Jolie '. 1 Department of Neurology. 2Departmentof Neurosurgery. Clinical Centre, Nis. Yugoslavia Brainstemauditoryevokedpotentials(BAEPs) have beenwidelyusedin the last two decadesas a diagnostictool to assess the functionof brainstem in patients with severe head injury.In this paper,BAEPswere analysed in 32 coma patients and related to the Insbruc Coma Scale (ICS) and neuroradiological parameters (CT· scan). The neurophysiological investigations (BAEPs) were carried out with the
Head Inju ry - Pathophysiology of Head Injury
569
devices (SAPPHIRE-MEDELEC according to D. Jewell method (1971) in the modification of G. AvakionS. Groppa (1984). The dysfunction of the brainstem at different levels of coma was established. Abnonmal BAEPs were demonstrated more frequentlyin patients with low score of ICS, but did not correlatewith CTscan findings. Our findings emphasize the importance of BAEPsin evaluating dysfunction of brainstem in coma patientsin correlation with ICS and CT- scan.
IP-2-151 I patients Diagnostic and prognostic importance of MEPs in with severe head trauma J. stamenovtc " S. Djurie 1, Z. Milenkovie 2 , M. Jolic ", G. Ignjatovie2, I. Stefanovic 2. A. llie 1. 1 Departmentof Neurology, 2 Department of Neurosurgery, Clinical Centre, Nis. Yugoslavia In 60 patients with severe head trauma, diagnostic and prognostic importance of multimodal evoked potentials/MEPsi was evaluated in relation to duration of coma and outcome. The Innsbruck Coma Scale flCSf for evaluation of the coma level and GlasgowOutcomeScale /GOS/ for the outcome were used. Analysis and measurements of the MEPs were performed many times in the period of assessment/six months after injury/. Our results of MEPs show different correlations and sensitivityin relation to the duration of coma and the outcomeof the injury. Somatosensory evoked potentialsfSEPsi and Brainstem auditory evoked potentials fBAEPs/ had the best correlation and the greatest sensitivity, while Visual evoked potentials N EPsi had the lowest degree of sensitivity. The goal of this study was the evaluation of early diagnostic sensitivity and prognosticimportance of MEPs in the early period after severe head trauma.
IP-2-152 I Study Polysomnography on traumatic vegetative patients: in sleep and wakefulness pattern at night M. Kono, Y. Ono", T. Horie, K. Taniguti, N. a ka, M. Odaki. Chiba Ryogo Center, Chiba. Japan. 1 Tsukuba Medical Center, Tsukuba. Japan 67 Patients were admitted into Chiba Ryogo Center in a post traumatic vegetative stale (PVS) in 11 years. 49 patients (41 males, and 8 females) of them were studied. 1) Is there any difference between sleep and wakefulness in polysomnography? 2) Is it possible to identify the stage of sleep? 3) Is it possible to predict the outcomein PVS based on pattern of polysomnography? On multipurposemultichannelEEGrecorder, 14Channelsof EEG,horizontal and vertical ENG, EMG of masseter, ECG and respiration curve were observed and recorded for 12 hours from 8:00 PM to 8:00 AM, and simultaneously recorded on magnetic tape. Each sleep stage was investigated and reviewed by the methodof Rechtschaffen & Kales (R&K). NSWS spindle(+) NSWSspindle(- )
32 cases 17
SWS
41
REM
45
65.3% 34.7% 83.7% 91.8%
All cases showed EMG artifact and blinking artifact in wakefulness. In those cases of difficult identifiablealpha waves, attenuation or disappearance of artifacts werethe most significantfindings of hypnagogicstate. Sleep-wakefulness pallem could be classified in 4 stages: WakefUlness, Non slow-wave Sleep (NSWS) including the first and the second stage of R&K, SWS including the third and the forth stage of R&K and REM sleep.
Monday, 7 July 1997
P-2
14:00-16:15
Head Injury - Pathophysiology of Head Injury
Age- and sex-related changes of 5-100 protein IP-2-153I concentrations in cerebrospinal fluid and serum in patients with no previous history of neurological disorder 0ystein Nygaard, Bodil Langbakk ' , Bertil Romner. Department of Neurosurgery. 1 Department of Clinica/ Chemistry, University Hospital of Itomse , 9038 Trams", Norway Introduction: Studiesof cerebrospinal fluid (CSF) concentrations of S-100 protein in patientswith neurological lesions indicate a quantitativerelationbetween
=
IP-2-14SI Noninvasive multimodal cerebral monitoring of head-injured patients in ICU V. Amcheslavski, G. Toma, G. Margishvili. S.V. Madorski, A. Parfenov, E. Gaitur, A. Ostrovski. Burdenko Neurosurgicallnstitut. Moscow. Russia Introduction: One of the goals of noninvasive multimodal cerebral monitoring (NMCM)in critically ill patientswith severe head injury (HI) is the earlydetection and prevention of secondarybrain damagedue to ischemia. Methods: NMCM was used in 21 patients with severe HI. We preferred the bedside and non-invasive methods: 1) TCD for measurement of CBF velocity (Transpect Medasonics, Germany; Sonas2500 HP, USA); 2) NIRS(Cerebral OximeterInvos3100 Somanetics, USA) for investigation of cerebral oxygenation (CO); 3) registration of SSEP (Phasis, ESAOTE Biomedica, Italy) that provide definiteinformation on theintegrity of neuralpathways. This combinationof methods in addition to detailed neurological examination allowed us to receive more complete infonmation about functional, anatomical and metabolicstateof brain. Results: The patients were divided into 3 groups according to Gas. 1stpatients with fatal outcome(4); 2nd - patients with severe disability or vegetative state (6); 3rd - patients with good recovery or moderate disability (11). In the 1-st group high values of CBF velocity (227 ± 7 sm/sec) in both artery cerebri media, bilateral absence of SSEP, bilateral changes of CO unresponsive to therapeutic measures were revealed. In the 2-nd group -high values of CBF velocity (211 ± 15 sm/sec), predominantly on one side, with the peak on the 11·th day were observed. CBF velocity came to normal values 17-21 days after HI. Disturbancesof CO were revealed on the side of vasospasm and came to nonmal values 7- 14 days after HI. Disturbancesof SSEPwere asymmetric and persistent with improvement of SSEP in 2 cases. In the 3-rd group -moderate bilateral increase of CBF velocity (140 ± 8 sm/sec). normal values of CO, asymmetrical mild and reversible changes of SSEP were observed. Conclusion: NMCM can be useful for predicting the prognosis for recovery after HI. This combination of methods allowed assessment of the integrity of the brain during critical period in HI.
I P-2-149I Multi evoked potential study and CT scan in patients with brain contusion S. Djuric' , Z. Milenkovie2 , M. Jolie 1 , A. llie 1, I. Stefanovie 2 , J. stamenovlc 1. of Neurology, Clinical Centre. Nis, Yugoslavia. 2 Department of Neurosurgery, Clinical Centre. Nis. Yugoslavia
1 Department
Multi·evoked potentials (MEPs) are recognized as a useful technique in clinical neurophysiology and have also been advocatedas a sensitive measure in brain contusion. in order to detect an abnormal function of the peripheral and central nervous system. All patients (32) with braincontusion underwentneurological, neuroradtoloqical (CT·scan) and neurophysiological evaluations in the threedays after injury. Neurophysiological parameters were analysed as well as the relationships with clinical and neuroradiological findings. Abnormal function of brain by MEPswas observed in 28 patients (87.5%) and neuroradiological findings were abnormal in 19 patients (59.4%). Our results show high diagnostic sensitivity of MEPs, while there was no correlation with neuroradiological parameters.
IP-2-150 I Short of ~rainstem audltory evoked potentials in coma patients M. Jolie 1 , S. Djurie 1 , G. IgnjatoviC 2, I. Statanovic 2, M. Lazarevic 1 , J. Starnenovic 1 , S. Jolie '. 1 Department of Neurology. 2Departmentof Neurosurgery. Clinical Centre, Nis. Yugoslavia Brainstemauditoryevokedpotentials(BAEPs) have beenwidelyusedin the last two decadesas a diagnostictool to assess the functionof brainstem in patients with severe head injury.In this paper,BAEPswere analysed in 32 coma patients and related to the Insbruc Coma Scale (ICS) and neuroradiological parameters (CT· scan). The neurophysiological investigations (BAEPs) were carried out with the
Head Inju ry - Pathophysiology of Head Injury
569
devices (SAPPHIRE-MEDELEC according to D. Jewell method (1971) in the modification of G. AvakionS. Groppa (1984). The dysfunction of the brainstem at different levels of coma was established. Abnonmal BAEPs were demonstrated more frequentlyin patients with low score of ICS, but did not correlatewith CTscan findings. Our findings emphasize the importance of BAEPsin evaluating dysfunction of brainstem in coma patientsin correlation with ICS and CT- scan.
IP-2-151 I patients Diagnostic and prognostic importance of MEPs in with severe head trauma J. stamenovtc " S. Djurie 1, Z. Milenkovie 2 , M. Jolic ", G. Ignjatovie2, I. Stefanovic 2. A. llie 1. 1 Departmentof Neurology, 2 Department of Neurosurgery, Clinical Centre, Nis. Yugoslavia In 60 patients with severe head trauma, diagnostic and prognostic importance of multimodal evoked potentials/MEPsi was evaluated in relation to duration of coma and outcome. The Innsbruck Coma Scale flCSf for evaluation of the coma level and GlasgowOutcomeScale /GOS/ for the outcome were used. Analysis and measurements of the MEPs were performed many times in the period of assessment/six months after injury/. Our results of MEPs show different correlations and sensitivityin relation to the duration of coma and the outcomeof the injury. Somatosensory evoked potentialsfSEPsi and Brainstem auditory evoked potentials fBAEPs/ had the best correlation and the greatest sensitivity, while Visual evoked potentials N EPsi had the lowest degree of sensitivity. The goal of this study was the evaluation of early diagnostic sensitivity and prognosticimportance of MEPs in the early period after severe head trauma.
IP-2-152 I Study Polysomnography on traumatic vegetative patients: in sleep and wakefulness pattern at night M. Kono, Y. Ono", T. Horie, K. Taniguti, N. a ka, M. Odaki. Chiba Ryogo Center, Chiba. Japan. 1 Tsukuba Medical Center, Tsukuba. Japan 67 Patients were admitted into Chiba Ryogo Center in a post traumatic vegetative stale (PVS) in 11 years. 49 patients (41 males, and 8 females) of them were studied. 1) Is there any difference between sleep and wakefulness in polysomnography? 2) Is it possible to identify the stage of sleep? 3) Is it possible to predict the outcomein PVS based on pattern of polysomnography? On multipurposemultichannelEEGrecorder, 14Channelsof EEG,horizontal and vertical ENG, EMG of masseter, ECG and respiration curve were observed and recorded for 12 hours from 8:00 PM to 8:00 AM, and simultaneously recorded on magnetic tape. Each sleep stage was investigated and reviewed by the methodof Rechtschaffen & Kales (R&K). NSWS spindle(+) NSWSspindle(- )
32 cases 17
SWS
41
REM
45
65.3% 34.7% 83.7% 91.8%
All cases showed EMG artifact and blinking artifact in wakefulness. In those cases of difficult identifiablealpha waves, attenuation or disappearance of artifacts werethe most significantfindings of hypnagogicstate. Sleep-wakefulness pallem could be classified in 4 stages: WakefUlness, Non slow-wave Sleep (NSWS) including the first and the second stage of R&K, SWS including the third and the forth stage of R&K and REM sleep.
Monday, 7 July 1997
P-2
14:00-16:15
Head Injury - Pathophysiology of Head Injury
Age- and sex-related changes of 5-100 protein IP-2-153I concentrations in cerebrospinal fluid and serum in patients with no previous history of neurological disorder 0ystein Nygaard, Bodil Langbakk ' , Bertil Romner. Department of Neurosurgery. 1 Department of Clinica/ Chemistry, University Hospital of Itomse , 9038 Trams", Norway Introduction: Studiesof cerebrospinal fluid (CSF) concentrations of S-100 protein in patientswith neurological lesions indicate a quantitativerelationbetween