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Advances in Neuromonitoring and Water Transport Mechanisms in the Brain

This article explores recent developments in neuromonitoring, focusing on methodologies for assessing intracranial pressure (ICP) and the role of aquaporins in brain water transport. It highlights the significance of accurate monitoring techniques including non-invasive methods and the importance of understanding brain edema following trauma. By reviewing current literature on the molecular mechanisms of water transport and the effects of intracranial pressure patterns, the article provides insights into potential implications for clinical practice and patient outcomes.

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Advances in Neuromonitoring and Water Transport Mechanisms in the Brain

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  1. Theblackboxrevelation What’snewinneuromonitoring? GiuseppeCiterio

  2. !Waterandthebrain !Monitoring !Conclusions

  3. Capillarystructure:centralnervous system“BBB”

  4. AdrogueHJ,MadiasNE.Reviewarticle:HYPONATREMIA.NEnglJMed2000;342:1581-9.AdrogueHJ,MadiasNE.Reviewarticle:HYPONATREMIA.NEnglJMed2000;342:1581-9.

  5. Distributioninbrain ofaquaporin-1 (AQP1,blue) andAQP4 (orange) Amiry-Moghaddam,M.,&Ottersen,O.P.(2003).Themolecularbasisofwatertransportinthebrain.NatureReviewsNeuroscience,4(12),991–1001.doi:10.1038/nrn1252

  6. Architectureofthe aquaporin-1 Amiry-Moghaddam,M.,&Ottersen,O.P.(2003).Themolecularbasisofwatertransportinthebrain.NatureReviewsNeuroscience,4(12),991–1001.doi:10.1038/nrn1252

  7. Amiry-Moghaddam,M.,Frydenlund,D.S.,&Ottersen,O.P.(2004).AnchoringAmiry-Moghaddam,M.,Frydenlund,D.S.,&Ottersen,O.P.(2004).Anchoring ofaquaporin-4inbrain:molecularmechanismsandimplicationsforthe physiologyandpathophysiologyofwatertransport.Neuroscience,129(4), 999–1010.doi:10.1016/j.neuroscience.2004.08.049

  8. Postischemicedema(22hfollowing90minof MCAO) With aquaporins NO aquaporins Amiry-Moghaddam,M.,Frydenlund,D.S.,&Ottersen,O.P.(2004).Anchoring ofaquaporin-4inbrain:molecularmechanismsandimplicationsforthe physiologyandpathophysiologyofwatertransport.Neuroscience,129(4), 999–1010.doi:10.1016/j.neuroscience.2004.08.049

  9. ModifiedfromUnterberg,A(2004).Edemaand braintrauma.NSC,129(4),1021–1029.

  10. ModifiedfromUnterberg,A(2004).Edemaand braintrauma.NSC,129(4),1021–1029.

  11. Howtomonitorit?

  12. The“net”effect:increaseinvolume P ICP V LangfittTWetal,JNeurosurg,1964

  13. CTscanissuggestivebutcan’tmeasureit Normal Brainedema

  14. Invasivemonitoringsystems

  15. Oddsratiosofneurologicaloutcomesat1year, comparingintracranialpressure(ICP)patterns Oddsratiosand95%confidenceintervals[95%CI]ofneurologicaloutcomesat1 year,comparingintracranialpressure(ICP)patterns GlasgowOutcomeScore:GR,GoodRecovery;MD,ModerateDisability;SD,Severe Disability;V,Vegetative;D,Death Roleofintracranialpressurevaluesandpatternsinpredictingoutcomeintraumaticbraininjury:asystematicreview. Treggiari.NeurocritCare(2007)6:104–112

  16. patientswith(■)andwithout(☐)global cerebraledema(GCE) Helbok,R.,Ko,S.B.,Schmidt,J.M.,Kurtz,P.,Fernandez,L.,Choi,H.A.,Connolly,E.S.,etal.(2011).GlobalCerebralEdemaandBrainMetabolismAfterSubarachnoidHemorrhage. Stroke.doi:10.1161/STROKEAHA.110.604488

  17. Ultrasonographyofopticnervesheathdiameterfor detectionofraisedintracranialpressure Soldatos,T.,Chatzimichail,K.,Papathanasiou,M.,&Gouliamos,A.(2009).Optic nervesonography:anewwindowforthenon-invasiveevaluationofintracranial pressureinbraininjury.EmergencyMedicineJournal,26(9),630–634.doi:10.1136/ emj.2008.058453 Geeraerts,T.,Newcombe,V.F.J.,Coles,J.P.,Abate,M.G.,Perkes,I.E.,Hutchinson,P.J.A., Outtrim,J.G.,etal.(2008).UseofT2-weightedmagneticresonanceimagingoftheopticnerve sheathtodetectraisedintracranialpressure.Criticalcare(London,England),12(5),R114.doi: 10.1186/cc7006

  18. DubourgJUltrasonographyofopticnervesheathdiameterfordetectionDubourgJUltrasonographyofopticnervesheathdiameterfordetection ofraisedintracranialpressure:asystematicreviewandmeta-analysis. IntensiveCareMed.2011;37(7):1059–1068.

  19. Anewapproach Goldstein,B.,Tasker,R.C.,&Wakeland,W.(2012).FromLundbergtoSIM-ICP:ComputationalPhysiologyandModelingIntracranialPressure. Sciencetranslationalmedicine,4(129),129fs6.doi:10.1126/scitranslmed.3003925

  20. Kashif,F.M.,Verghese,G.C.,Novak,V.,Czosnyka,M.,&Heldt,T.(2012).Model-basednoninvasiveestimationofintracranialpressurefromcerebralbloodKashif,F.M.,Verghese,G.C.,Novak,V.,Czosnyka,M.,&Heldt,T.(2012).Model-basednoninvasiveestimationofintracranialpressurefromcerebralblood flowvelocityandarterialpressure.Sciencetranslationalmedicine,4(129),129ra44.doi:10.1126/scitranslmed.3003249

  21. (A)ICPandnICPon2665nonoverlapping windowsfrom45patientrecords. (B)ICPandnICPon1673nonoverlapping windowsfrom30recordswithbilateral CBFVrecordings, (C)ICPandnICPaveragedacrossall windowsineachof45patientrecords. Kashif,F.M.,Verghese,G.C.,Novak,V.,Czosnyka,M.,&Heldt,T.(2012).Model-basednoninvasiveestimationofintracranialpressurefromcerebralblood flowvelocityandarterialpressure.Sciencetranslationalmedicine,4(129),129ra44.doi:10.1126/scitranslmed.3003249

  22. Intracranialpressure Whenwatercontentincreases,volumeincreases. Therefore,ICPcouldrise. InvasiveICPmonitoring ✓Sensitivity:HIGH ✓Notspecific!!

  23. Braintissueoxygenation

  24. PbrO2andedema LeachRMandTreacherDFBMJ1998;317:1370-73 Moppett,I.K.,&Hardman,J.G.(2007).Modelingthecausesofvariationinbraintissueoxygenation. Anesthesia&Analgesia,105(4),1104–12–tableofcontents.doi:10.1213/01.ane.0000281934.99076.89

  25. patientswith(■)andwithout(☐)globalcerebraledema(GCE Helbok,R.,Ko,S.B.,Schmidt,J.M.,Kurtz,P.,Fernandez,L.,Choi,H.A.,Connolly,E.S.,etal.(2011).GlobalCerebralEdemaand BrainMetabolismAfterSubarachnoidHemorrhage.Stroke.doi:10.1161/STROKEAHA.110.604488

  26. Fletcher,J.J.,Bergman,K.,Blostein,P.A.,&Kramer,A.H.(2010).Fluidbalance,complications,andbraintissueoxygentensionFletcher,J.J.,Bergman,K.,Blostein,P.A.,&Kramer,A.H.(2010).Fluidbalance,complications,andbraintissueoxygentension monitoringfollowingseveretraumaticbraininjury.NeurocriticalCare,13(1),47–56.doi:10.1007/s12028-010-9345-2

  27. PbrO2 Whenwatercontentincreases,diffusivityofO2isdecreased. Therefore,PbrO2coulddecrease. PbrO2 !Sensitivity:MEDIUM !Notspecific!!

  28. Microdyalisis

  29. patientswith(■)andwithout(☐)globalcerebraledema(GCE Helbok,R.,Ko,S.B.,Schmidt,J.M.,Kurtz,P.,Fernandez,L.,Choi,H.A.,Connolly,E.S.,etal.(2011).GlobalCerebralEdemaand BrainMetabolismAfterSubarachnoidHemorrhage.Stroke.doi:10.1161/STROKEAHA.110.604488

  30. Microdyalisis Whenwatercontentincreases,ischemiacoulddevelop. Therefore,L/Pcouldincrease. L/P !Sensitivity:MEDIUM !Notspecific!!

  31. Howtoincreasespecificity?

  32. Lescot,T.,Bonnet,M.-P.,Zouaoui,A.,Muller,J.-C.,Fetita,C.,Coriat,P.,&Puybasset,L.(2005).Aquantitativecomputedtomographyassessmentofbrainweight,Lescot,T.,Bonnet,M.-P.,Zouaoui,A.,Muller,J.-C.,Fetita,C.,Coriat,P.,&Puybasset,L.(2005).Aquantitativecomputedtomographyassessmentofbrainweight, volume,andspecificgravityinsevereheadtrauma.IntensiveCareMedicine,31(8),1042–1050.doi:10.1007/s00134-005-2709-y

  33. Apparentdiffusioncoefficient-ADC H2O Cytotoxic Vasogenic

  34. Axialdiffusivity

  35. Axialdiffusivity

  36. ThermalDiffusionFlowmetry PassiveThermistor Activethermistor

  37. ThermalDiffusionFlowmetry 1mm •Determinationoftissue conduction=Thermal Conductivity[K-value]inbrain tissue •Extractionofconvection =heattransferwithinthefield •Calculationofperfusion =amountofpowertomaintain temperatureincrementof2-3 °Cabovebaseline Passive thermistor 8mm Active thermistor Temperature Measurementdiameter=8mm

  38. Ko,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).RealtimeestimationofbrainKo,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).Realtimeestimationofbrain watercontentincomatosepatients.AnnalsofNeurology,n/a–n/a.doi:10.1002/ana.23619

  39. Ko,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).RealtimeestimationofbrainKo,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).Realtimeestimationofbrain watercontentincomatosepatients.AnnalsofNeurology,n/a–n/a.doi:10.1002/ana.23619

  40. Ko,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).RealtimeestimationofbrainKo,S.-B.,AlexChoi,H.,Parikh,G.,MichaelSchmidt,J.,Lee,K.,Badjatia,N.,Claassen,J.,etal.(2012).Realtimeestimationofbrain watercontentincomatosepatients.AnnalsofNeurology,n/a–n/a.doi:10.1002/ana.23619

  41. !Waterinthebrainistightlycontrolled. !BrainedemaisassociatedwithHICPandworseoutcome !Increaseinwatercontentcouldbeevaluated(evenifNOT SPECIFIC)with: !ICP !PbrO2 !Microdyalisis !Imagingcouldhelpindefiningbrainedema !WatercontentinthebraincouldbemonitoredwithThermal DiffusionFlowmetry

  42. Thankyoufortheattention

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