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4. International e-Delphi survey to define best practice in the reporting of intracranial pressure monitoring recording data.

Author

Kommer, Maya, Hawthorne, Christopher, Moss, Laura, Piper, Ian, OKane, Roddy, Czosnyka, Marek, Enblad, Per, Hemphill, J, Spiegelberg, Andreas, Riddell, John, and Shaw, Martin

Subjects
Hydrocephalus, Intracranial pressure monitoring, Traumatic brain injury
Abstract

INTRODUCTION: Intracranial pressure (ICP) monitoring is a very commonly performed neurosurgical procedure but there is a wide variation in how it is reported, hindering analysis of it. The current study sought to generate consensus on the reporting of ICP monitoring recording data. RESEARCH QUESTION: What should be included in an ICP monitoring report? MATERIAL AND METHODS: The exercise was completed via a modified eDelphi survey. An expert panel discussion was held from which themes were identified and used to produce a code to annotate the transcript of the discussion. Statements were generated for a further two rounds of electronic questionnaires distributed via the REDcap platform. A Likert scale was used to grade agreement with each statement in the survey. A statement was accepted if more than 70% agreement was achieved between respondents. Data was collated using Microsoft Excel and analysed using R. RESULTS: 149 relevant statements were identified from the transcript and categorised into recording parameters, waveform characteristics or reporting. A total of 22 statements were generated for the first round of the survey which was answered by 39 respondents. Following the electronic round of surveys consensus was achieved for all but one statement regarding the acceptability of automating ICP reporting. This was put forward to a second round after which 79% agreement was reached. DISCUSSION AND CONCLUSION: The themes and statements from this eDelphi can be used as a framework to allow the standardisation of the reporting of intracranial pressure monitoring data.

Published
2024

26. Individualized Autoregulation-Derived Cerebral Perfusion Targets in Aneurysmal Subarachnoid Hemorrhage: A New Therapeutic Avenue?

Author

Svedung Wettervik, Teodor Mikael, Hånell, Anders, Howells, Timothy, Ronne-Engström, Elisabeth, Lewén, Anders, and Enblad, Per

Subjects
SUBARACHNOID hemorrhage, UNIVERSITY hospitals, PERFUSION, SCIENTIFIC observation, PERCENTILES
Abstract

Background: Cerebral perfusion pressure (CPP) is an important target in aneurysmal subarachnoid hemorrhage (aSAH), but it does not take into account autoregulatory disturbances. The pressure reactivity index (PRx) and the CPP with the optimal PRx (CPPopt) are new variables that may capture these pathomechanisms. In this study, we investigated the effect on the outcome of certain combinations of CPP or ΔCPPopt (actual CPP-CPPopt) with the concurrent autoregulatory status (PRx) after aSAH. Methods: This observational study included 432 aSAH patients, treated in the neurointensive care unit, at Uppsala University Hospital, Sweden. Functional outcome (GOS-E) was assessed 1-year postictus. Heatmaps of the percentage of good monitoring time (%GMT) of PRx/CPP and PRx/ΔCPPopt combinations in relation to GOS-E were created to visualize the association between these variables and outcome. Results: In the heatmap of the %GMT of PRx/CPP, the combination of lower CPP with higher PRx values was more strongly associated with lower GOS-E. The tolerance for lower CPP values increased with lower PRx values until a threshold of −0.50. However, for decreasing PRx below −0.50, there was a gradual reduction in the tolerance for lower CPP. In the heatmap of the %GMT of PRx/ΔCPPopt, the combination of negative ΔCPPopt with higher PRx values was strongly associated with lower GOS-E. In particular, negative ΔCPPopt together with PRx above +0.50 correlated with worse outcomes. In addition, there was a transition toward an unfavorable outcome when PRx went below −0.50, particularly if ΔCPPopt was negative. Conclusions: The PRx levels influenced the association between CPP/ΔCPPopt and outcome. Thus, this variable could be used to individualize a safe CPP-/ΔCPPopt-range. [ABSTRACT FROM AUTHOR]

Published
2024
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29. Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes: A Multi-Center Observational Cohort Study

Author

Fletcher-Sandersjöö, Alexander, primary, Svedung Wettervik, Teodor, additional, Tatter, Charles, additional, Tjerkaski, Jonathan, additional, Nelson, David W., additional, Maegele, Marc, additional, Svensson, Mikael, additional, Lewén, Anders, additional, Enblad, Per, additional, Bellander, Bo-Michael, additional, and Thelin, Eric Peter, additional

Published
2024
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30. Surgery Outside Neurosurgical Units

Author

Enblad, Per, Sundstrøm, Terje, editor, Grände, Per-Olof, editor, Luoto, Teemu, editor, Rosenlund, Christina, editor, Undén, Johan, editor, and Wester, Knut Gustav, editor

Published
2020
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33. Absolute Contusion Expansion Is Superior to Relative Expansion in Predicting Traumatic Brain Injury Outcomes : A Multi-Center Observational Cohort Study

Author

Fletcher-Sandersjöö, Alexander, Svedung Wettervik, Teodor, Tatter, Charles, Tjerkaski, Jonathan, Nelson, David W., Maegele, Marc, Svensson, Mikael, Lewén, Anders, Enblad, Per, Bellander, Bo-Michael, Thelin, Eric Peter, Fletcher-Sandersjöö, Alexander, Svedung Wettervik, Teodor, Tatter, Charles, Tjerkaski, Jonathan, Nelson, David W., Maegele, Marc, Svensson, Mikael, Lewén, Anders, Enblad, Per, Bellander, Bo-Michael, and Thelin, Eric Peter

Abstract

Contusion expansion (CE) is a potentially treatable outcome predictor in traumatic brain injury (TBI), and a suitable end-point for hemostatic therapy trials. However, there is no consensus on the definition of clinically relevant CE, both in terms of measurement criteria (absolute vs. relative volume increase) and cutoff values. In light of this, the aim of this study was to assess the predictive abilities of different CE definitions on outcome. We performed a multi-center observational cohort study of adults with moderate-to-severe TBI treated in an intensive care unit. The exposure of interest was CE, defined as the absolute and relative volume change between the first and second computed tomography scan. The primary outcome was the Glasgow Outcome Scale (GOS) at 6–12 months post-injury, dichotomized into unfavorable (GOS ≤3) or favorable (GOS ≥4). The secondary outcome was all-cause mortality. In total, 798 patients were included, with a median duration of 7.0 h between the first and second CT scan. The median absolute and relative CE was 1.5 mL (interquartile range [IQR] 0.1–8.3 mL) and 100% (IQR 10–530%), respectively. Both CE forms were independently associated with unfavorable GOS. Absolute CE outperformed relative CE in predicting both unfavorable GOS (area under the curve [AUC]: 0.65 vs. 0.60, p = 0.002) and all-cause mortality (AUC: 0.66 vs. 0.60, p = 0.003). For dichotomized CE, absolute cutoffs of 1–10 mL yielded the best results. We conclude that absolute CE demonstrates stronger outcome correlation than relative CE. In studies focusing on lesion progression in TBI, it may be advantageous to use absolute CE as the primary outcome metric. For dichotomized outcomes, cutoffs between 1 and 10 mL are suggested, depending on the desired sensitivity-specificity balance., De två första författarna delar förstaförfattarskapet

Published
2024
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34. Diagnosis of external ventricular drainage related infections with real-time 16S PCR and third-generation 16S sequencing

Author

Widen, Johan, Morén, Jakob, Mölling, Paula, Fagerström, Anna, Enblad, Per, Eriksson, Britt-Marie, Ronne-Engström, Elisabeth, Sundqvist, Martin, Westman, Gabriel, Widen, Johan, Morén, Jakob, Mölling, Paula, Fagerström, Anna, Enblad, Per, Eriksson, Britt-Marie, Ronne-Engström, Elisabeth, Sundqvist, Martin, and Westman, Gabriel

Abstract

Objective: Investigate the performance of real-time 16S PCR and third-generation 16S sequencing in the diagnosis of external ventricular drain related infections (EVDRI). Methods: Subjects with suspected EVDRI were prospectively included at Uppsala University Hospital. Subjects were included into three groups: subjects with negative CSF culture with and without antibiotic treatment and subjects with positive CSF culture, respectively. CSF was analysed with real-time 16S PCR and third-generation 16S sequencing. Real-time 16S PCR positivity/negativity and number of 16S sequence reads were compared between groups. For culture positive subjects, species identification in third-generation sequencing and routine culture was compared. Results: 84 subjects were included. There were 18, 44 and 22 subjects in the three groups. Real-time PCR was positive in 17 of 22 subjects in the culture positive group and negative in 61 of the 62 subjects in the two culture negative groups. The sensitivity and specificity for real-time 16S PCR compared to culture was estimated to 77% and 98%, respectively. Species identification in 16S sequencing and culture was concordant in 20 of 22 subjects. The number of 16S sequence reads were significantly higher in the culture positive group than in both culture negative groups (p < 0.001). There was no significant difference in number of 16S sequences between the two culture negative groups. Conclusions: Real-time 16S PCR predict culture results with sufficient reliability. Third-generation 16S sequencing could enhance sensitivity and species identification in diagnostics of EVD-related infections. False negative culture results appear to be uncommon in patients with suspected EVDRI., W received financing for his work with this study by grants from the Swedish state under the agreement between the Swedish government and the county councils, the ALF-agreement (grant number 2019-ST0044).GW received funding from the Regional Research Council Mid Sweden (Sjukvårdsregionalaforskningsrådet Mellansverige) for his work with this study (grant number RFR-560661 and RFR-981134).JM received funding from the family Olinder-Nielsen’s foundation (Stiftelsen Familjen Olinder-Nielsens fond f€or infektionsmedicinsk-forskning) for his work with this study.

Published
2024
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41. Inaugural State of the Union: Continuous Cerebral Autoregulation Monitoring in the Clinical Practice of Neurocritical Care and Anesthesia.

Author

Park, Soojin, Beqiri, Erta, Smielewski, Peter, Aries, Marcel, Abecasis, Francisco, Agrawal, Shruti, Appavu, Brian, Balu, Ramani, Brady, Ken, Brunsch, Celina, Budohoski, Karol, Czigler, András, Depreitere, Bart, Dias, Celeste, Enblad, Per, Ercole, Ari, Figaji, Anthony, Foreman, Brandon, Frisvold, Shirin K., and Gallagher, Clare

Subjects
CEREBRAL circulation, INTRACRANIAL pressure, CLINICAL trials monitoring, CRITICALLY ill, ANESTHESIA, BLOOD pressure
Abstract

How continuous cerebral autoregulation (CCA) knowledge should be optimally gained and interpreted is still an active area of research and refinement. We now experience a unique situation of having indices clinically available before definitive evidence of benefit or practice guidelines, in a moment when high rates of institutional variability exist both in the application of monitoring as well as in monitoring-guided treatments. Responses from 47 international clinicians, experts in this field, were collected with polling and discussion of the results. The clinical use of CCA in critical illness was not universal among experts, with 34% not using it. Of those who use a CCA index in clinical practice, 64% use intracranial pressure–based Pressure Reactivity index (PRx). There seems to exist a considerable trust in the physiologic plausibility of CCA to guide individual arterial blood pressure and cerebral perfusion pressure therapy and provide benefit, regardless of the difficulty of proving this. A total of 59% feel the need for phase II and III prospective studies but would continue to use CCA information in their practice even if randomized controlled trials (RCTs) did not show clear clinical benefit. There was nearly universal interest to participate in an RCT, with agreement that the research community must together determine end points and interventions to reduce wasted effort and time, and that investigations should include the following: the most appropriate way of inclusion of CCA into the clinical workflow; whether CCA-guided interventions should be prophylactic, proactive; or reactive; and whether a CCA-centric (unimodal) or a multimodal monitoring-integrated tiered therapy approach should be adopted. Pediatric and neonatal populations were highlighted as having urgent need and even more plausibility than adults. On the whole, the initiative was enthusiastically embraced by the experts, with the general feeling that a strong push should be now made by the community to convert the plausible benefits of CCA monitoring, already implemented in some centers, into a more standardized and RCT-validated clinical reality. [ABSTRACT FROM AUTHOR]

Published
2024
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48. Visualizing Cerebrovascular Autoregulation Insults and Their Association with Outcome in Adult and Paediatric Traumatic Brain Injury

Author

Flechet, Marine, Meyfroidt, Geert, Piper, Ian, Citerio, Giuseppe, Chambers, Iain, Jones, Patricia A., Lo, Tsz-Yan Milly, Enblad, Per, Nilsson, Pelle, Feyen, Bart, Jorens, Philippe, Maas, Andrew, Schuhmann, Martin U., Donald, Rob, Moss, Laura, Van den Berghe, Greet, Depreitere, Bart, Güiza, Fabian, Steiger, Hans-Jakob, Series Editor, and Heldt, Thomas, editor

Published
2018
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49. Cerebral Perfusion Pressure Variability Between Patients and Between Centres

Author

Depreitere, Bart, Güiza, Fabian, Piper, Ian, Citerio, Giuseppe, Chambers, Iain, Jones, Patricia A., Lo, Tsz-Yan M., Enblad, Per, Nilsson, Pelle, Feyen, Bart, Jorens, Philippe, Maas, Andrew, Schuhmann, Martina U., Donald, Rob, Moss, Laura, Van den Berghe, Greet, Meyfroidt, Geert, Steiger, Hans-Jakob, Series Editor, and Heldt, Thomas, editor

Published
2018
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