BRAIN INJURY MONITORING OF ICP Raised intracranial pressure (ICP) and low cerebral blood flow (CBF) are

e associated with ischaemia and poor outcome after brain injury. Therefore, many management protocols target these parameters. This overview summarizes the technical aspects of ICP and CBF monitoring, and their role in the clinical management of brain-injured patients. Furthermore, some applications of these methods in current research are highlighted. ICP is typically measured using probes that are inserted into one of the lateral ventricles or the brain parenchyma. Therapeutic measures used to control ICP have relevant side-effects and continuous monitoring is essential to guide such therapies. ICP is also required to calculate cerebral perfusion pressure which is one of the most important therapeutic targets in brain-injured patients. Several bedside CBF monitoring devices are available. However, most do not measure CBF but rather a parameter that is thought to be proportional to CBF. Frequently used methods include transcranial Doppler which measures blood flow velocity and may be helpful for the diagnosis and monitoring of cerebral vasospasm after subarachnoid haemorrhage or jugular bulb oximetry which gives information on adequacy of CBF in relation to the metabolic demand of the brain. Method Intraventricular catheter Epidural catheter Lumbar CSF pressure Advantages Provides true global ICP Ease of insertion Extracranial procedure Can be performed ambulatory Rare complications during procedure Low risk of infections Can be made permanent implants Disadvantages Allows for CSF drainage and administration of drugs Minimal risk of infection (no penetration of dura) May not reflect ICP Dangerous if ICP is very high Drift of the transducer output over time In-vivo calibration not possible Inaccurate if intraparenchymal gradients exist

Catheter-tip microtransducers (subdural or intra-parenchymal)

NONINVASIVE MONITORING OF INTRACRANIAL PRESSURE The use of (invasive) ICP monitoring in clinical practice is suboptimal because of the three main reasons: 1. The insertion of a catheter or transducer is traditionally done only by a neurosurgeon in a specialized facility. Many patients with acute intracranial hypertension are however treated in intensive care units of general hospitals or other medical centers that do not necessarily have a neurosurgeon. Although emerging data suggests that physicians who are not neurosurgeons, or even physician assistants could place subdural or parenchymal transducers with low complication rates, such practice would still be considered problematic in most intensive care units. As a result, ICP monitoring is not performed in many patients in whom it is indicated. 2. The risks associated with the procedure frequently outweigh the value of added diagnostic information. 3. Powerful neuro-imaging techniques (CT, MRI) are readily available that, in addition to providing other diagnostic information, allow for assessment of edema, bleeding, intracranial masses, or signs of increased ICP, and can therefore partially substitute for direct ICP monitoring. The signs of raised ICP on CT or MRI scan (attenuated visibility of sulci and gyri, changes in size of the lateral ventricles, poor distinction between the gray and white matter, and compression of the suprasellar and quadrigeminal cistern) are however only qualitative indicators, and may be inaccurate, especially if ICP has been chronically increased or slowly increasing so that the brain structures have had time to adapt. An assessment of ICP based on repeated CT or MRI scans would therefore be inefficient, expensive, and potentially dangerous for the patient (because neither CT nor MRI are allow for bedside assessment, which would require frequent transportation of the patient from the IC unit to the imaging facility). A method of ICP monitoring that requires no surgery and poses no risks of infection or hemorrhage would certainly be welcomed by medical professionals, and at the very least could become the new gold standard in neuro-intensive care units provided it is sufficiently accurate and easy to use. If the method is relatively inexpensive and does not require a specialist in order to be applied correctly, or can be automated to some degree, it could also find its way to various levels of the health care system with a potential to substantially modify the current concepts of management of patients with conditions accompanied with intracranial hypertension, including but not limited to TBI.

Methods for Noninvasive ICP Monitoring Object of Measurement Intracranial (including the bones of the cranium) Technique of Measurement Ultrasound time of flight techniques Transcranial Doppler ultrasonography Acoustic measure Magnetic resonance imaging (MRI) Electroencephalography (EEG) Tympanic membrane displacement Otoacoustic emission (OAE) Optic nerve sheath ultrasonography Ophthalmodynamometry Optical coherence tomography of retina Jugular vein

Extracranial