Multimodality Neuromonitoring in Adult Traumatic Brain Injury

A Narrative Review

Martin Smith, M.B.B.S., F.R.C.A., F.F.I.C.M.

Disclosures

Anesthesiology. 2018;128(2):401-415. 

In This Article

Abstract and Introduction

Abstract

Neuromonitoring plays an important role in the management of traumatic brain injury. Simultaneous assessment of cerebral hemodynamics, oxygenation, and metabolism allows an individualized approach to patient management in which therapeutic interventions intended to prevent or minimize secondary brain injury are guided by monitored changes in physiologic variables rather than generic thresholds. This narrative review describes various neuromonitoring techniques that can be used to guide the management of patients with traumatic brain injury and examines the latest evidence and expert consensus guidelines for neuromonitoring.

Introduction

TRAUMATIC brain injury (TBI) is a leading cause of death and disability worldwide. Clinical outcomes are determined not only by the severity of the initial injury but also by biochemical, excitotoxic, and inflammatory responses that lead to further (secondary) brain injury.[1] The management of TBI is based on the central concept that prevention of secondary brain injury is associated with improved outcomes. Neuromonitoring plays an important role in the management of TBI because it is able to assess multiple aspects of cerebral physiology and guide therapeutic interventions intended to prevent or minimize secondary injury.[2–4] No single neuromonitor is able to identify comprehensively the spectrum of pathophysiologic changes after TBI, and multimodality monitoring—the measurement of several variables simultaneously—provides a more comprehensive picture of the (patho)physiology of the injured brain and its response to treatment.[5] Assessment of cerebral hemodynamics, oxygenation, and metabolic status allow an individually tailored approach to patient management in which treatment decisions can be guided by monitored changes in physiologic variables rather than by predefined, generic thresholds.[4] Several monitoring techniques are available for clinical use (Table 1). Normal ranges and treatment thresholds for many monitored variables are derived from observational data studying a variety of correlates of tissue injury rather than clinical outcomes. Furthermore, there is uncertainty about which physiologic variables are the most clinically relevant, how and when they should be monitored, and whether monitoring is cost-effective and impacts outcome.[2] Expert consensus guidelines on multimodality neuromonitoring have been published by the Neurocritical Care Society and the European Society of Intensive Care Medicine after comprehensive review of the literature.[6]

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