Review Article

NEURO MONITORING- PRESENT STATUS

K J Choudhury
Senior Consultant, Neuroanaesthesiology & Pain Management, Indraprastha Apollo Hospitals, Sarita Vihar, New Delhi 110 076, India. E-mail:kjchoudhury@samvedana.org The nervous system can easily be examined in an awake patient; by clinical examination, electrophysiologic methods and MRI. It is difficult to elicit all the information by routine methods under anaesthesia and in an unconscious / brain injured patient. Proper monitoring of nervous system during surgery can reduce neural injury related to surgery or positioning. Similarly it can help improve outcome in patients with neuronal injury. Key words: Neuromonitoring, Infrared spectroscopy.

MONITORING OF BRAIN Monitoring of brain is an integral part of neuroanaesthesia & neuro-intensive care and can be classified into systemic and brain specific methods. Systemic monitoring includes invasive arterial blood pressure, end tidal carbon dioxide, oxygen saturation enables detection of gross global changes in physiology. Brain specific monitoring enables more focused assessment of brain. INTRACRANIAL PRESSURE (ICP) MONITORING Intracranial pressure (ICP) monitoring has become standard in many centers [1], is supplemented with the measurement of cerebral blood flow, brain tissue oxygenation and metabolism. Analysis of data collected from the different modalities of neuromonitoring gives us a better understanding of brain health. Cerebral Perfusion Pressure (CPP) is calculated from mean arterial pressure (MAP) ICP, and is a key determinant of targeted therapy in acute brain injury. Brain Trauma Foundation recommends CPP values between 5070mmHg [2]. However, there is significant inter individual variation of the optimal CPP within this range. One potential method of targeting CPP more accurately is by using the Pressure Reactivity Index (PRx) as an adjunct to CPP. PRx is calculated as a linear correlation coefficient between averaged arterial blood pressure and ICP from a time window of 3-4 minutes. Good cerebrovascular reactivity is associated with negative PRx and a poor reactivity with a positive PRx value. ASSESSMENT OF CEREBRAL BLOOD FLOW (CBF) Cerebral blood flow can be estimated non-invasively
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using transcranial Doppler ultrasonography or measured invasively using thermodilution flowmetry- a method which is still in its infancy. Direct measurement of CBF The only practical intraoperative measurement of CBF involves injection of radioactive xenon into carotid artery, followed by measurement of radioactivity washout with a gamma detector placed over specific area of the brain. The method cannot measure CBF over other areas of the brain and cannot distinguish flow at different depths and reflect average gray- white matter flow. The technique is not continuous; hence no information about CBF is most parts of surgery. TRANSCRANIAL DOPPLER (TCD) ULTRASONOGRAPHY TCD measures red cell Flow Velocity (FV) in real time using the Doppler shift principle, thereby deriving an indirect measure of CBF. Data are generally derived from the Middle Cerebral Artery (MCA) as it is easy to insonate (using a probe which transmits ultrasound waves at 2MHz), carries a large proportion of supratentorial blood and its location allows easy fixation of the probe (to keep the angle of insonation constant) for prolonged monitoring. The transtemporal window through the thin bone above the zygomatic arch is commonly used to insonate the proximal segment (M1) of the MCA. As the volume of blood flowing through a vessel depends on the velocity of the moving cells and the diameter of the vessel concerned, then for a given blood flow, the velocity will increase with decreases in vessel diameter.

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Applications of TCD There are many advantages of using TCD. It is noninvasive, relatively inexpensive and provides real time information with high temporal resolution.The most common use of TCD is in the assessment of flow velocity in patients who have suffered subarachnoid haemorrhage (SAH). An MCA FVmean above 120 cm s-1 is regarded as being significant [3] and may indicate either hyperaemia or vasospasm. TCD is also used in assessment of cerebral autoregulation and vasoreactivity to carbon dioxide (CO2) as loss of these mechanisms in patients with brain injury may indicate a poor prognosis. Autoregulation may be tested at the bedside using the Transient Hyperaemic Response Test (THRT), which assesses the hyperaemic response in the TCD waveform following 5-9 seconds of digital carotid artery compression [4]. TCD continues to draw attention as a potential method for non-invasive ICP and CPP measurement using flow velocity (FV), critical closing pressure of cerebral circulation or ultrasound propagation speed. Pulsatility index (PI or Gosling index), which reflects cerebrovascular resistance, can be calculated using flow velocity (PI = (FVsys-FVdias)/FVmean). A rise in the PI in the absence of cerebral blood vessel narrowing may represent raised intracranial pressure. Thermal Diffusion Flowmetry Thermal conductivity of cerebral cortical tissues varies proportionally with CBF and measurement of thermal diffusion at the cortical surface can be used for CBF determination [5]. A monitor that measures thermal diffusion flowmetry consists of two small metal plates, which are thermistors, one of which is heated. Insertion of a thermal diffusion (TD) probe on surface of brain at a cortical region of interest allows CBF to be calculated from the temperature difference between the plates. An intraparenchymal TD probe has also been evaluated and the results are encouraging [6]. Thermal diffusion flowmetry has the potential for bedside monitoring of cerebral perfusion at the tissue level but it is invasive and relatively expensive. CEREBRAL OXYGENATION Maintaining the balance between cerebral metabolic supply and demand underpins much of neurocritical care and neuroanaesthetic practice. Cerebral perfusion pressure and metabolic rate can be manipulated by a number of means but these are not benign interventions and do not guarantee the absence of regional oxygenation deficits. A bedside technique for the quantitative,
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continuous measurement of cerebral oxygen supply and demand is clearly highly desirable. Currently the methods available to monitor brain oxygenation include jugular bulb oximetry, direct brain tissue oxygen measurement and near infrared spectroscopy (NIRS). Jugular venous saturation (SjO2), is the most common method of assessing global brain oxygenation. Assuming constant arterial oxygenation, the SjO2 represents the balance between oxygen supply and demand of the brain. In health, flow-metabolism coupling maintains SjO2 between about 55 and 75%. These values are somewhat lower than mixed venous saturations, reflecting the brains relatively high metabolic requirements. Jugular venous saturation below 50% suggests a relative failure of oxygen supply compared to demand and such episodes have been demonstrated to predict poor outcome after head injury in a dose-dependent way. Low SjO2 is often seen in comatose patients with head injuries or subarachnoid haemorrhage; even when therapy is guided by invasive haemodynamic and intracranial pressure monitoring. One of SjO2 derived parameters, which can indicate adequacy of oxygen delivery to the brain is arterio-jugular difference of oxygen content (AJDO2)- higher mean AJDO2 is associated with better neurological outcome. This is an easy bed-side method, which can supplement patient assessment. Brain lactate level (measured from jugular venous blood) was shown to correlate with severity of injury and adverse outcome. Higher jugulo-arterial difference in lactate was found to have a predictive value for worse neurological outcome. However, although SjO2 is a considered to be a good global monitor of brain oxygenation, its main deficiency is the lack of sensitivity to focal or regional brain ischaemia. SjO2 level only falls to 50% when the volume of ischemic brain tissue reaches 135%. Continuous monitoring of SjO2 also has a number of practical problems, including a high proportion of false readings for a variety of reasons. NEAR INFRARED SPECTROSCOPY Near infrared spectroscopy (NIRS) is a non-invasive method of estimating regional cerebral oxygenation, in the areas of the brain targeted by probe placement. Biological tissues contain a number of light-absorbing pigments known as chromophores such as haemoglobin, myoglobin and cytochrome oxidase which have absorption spectra which depend on their redox state. These changes are reasonably pronounced in the near infrared part of the electromagnetic spectrum (700-1000 nm) where absorption from skin and bone is low. Such light can thus penetrate several centimetres through scalp and skull to non-invasively probe brain tissue. By measuring optical absorption at several wavelengths, relative tissue
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chromophore concentrations can be inferred in real time. NIRS as a clinical brain oxygenation monitor was initially used in neonates as the skull thickness is thin, thereby allowing near infrared light to transmit through the skull. Unfortunately as the neonate grows and the skull thickness and soft tissue increases in size and amount, this method becomes increasingly less possible. NIRS measurements in older children and adults use the principle of reflectance spectroscopy. The probes or optodes are placed 4-7cm apart on the same side of the forehead and thence track changes in cerebral oxygenation. The optodes are kept away from the midline, cerebral cavernous sinus and temporalis muscles and a relatively acute angle to each other. The normal range for readings is 60-80% where 47% is considered the ischaemic threshold. One of the most useful clinical applications in adults has been in the intraoperative monitoring of carotid endarterectomy, with cerebral desaturation demonstrated in 50% of patients after internal carotid artery crossclamping [7]. NIRS brain oximetry has also been evaluated as a method of preventing cerebral injury during cardiac surgery, and monitoring patients with traumatic brain injury in ICU. NIRS is completely non-invasive, portable, provides real-time temporal resolution and its relatively low cost makes the technique promising. BRAIN TISSUE OXYGEN TENSION Recent advancement in technology over the last decade has allowed the measurement of extracellular cerebral tissue oxygen tension (PbtO2) by inserting a Clark electrode microsensor directly into the cerebral parenchyma, either through a bolt or tunnelled from a craniotomy site. Oxygen from brain tissue within a few millimetres from the device diffuses into the sensor cell where it accepts electrons on a charged catalytic surface generating an electric current in proportion to the dissolved oxygen tension. Measured values of PbtO2 are accurate to within about 10% and values of around 22 mmHg are typical in health [8]. This is much lower than the oxygen tension of arterial blood reflecting the high metabolic requirements of cerebral tissue. Thresholds for ischaemia are not yet clearly defined but a PbtO2 of less than 8-10 mmHg seems to indicate a high risk of ischaemia. Brain Trauma Foundation (2007) recommends a treatment threshold of <15mmHg. Low values of PbtO2, particularly if they are sustained, are associated with poor outcome [9]. MONITORING OF CEREBRAL METABOLISM Microdialysis is a tool for sampling the brain extra
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cellular fluid for a range of molecules including fundamental substrates and metabolites, cytokines and drugs. It enables monitoring of the chemical milieu within the brain providing information on the underlying physiological and pathological processes that follow neuronal injury by inserting a microdialysis catheter into the brain parenchyma. Cerebral microdialysis is recommended in severe traumatic brain injury,which require monitoring of ICP and CPP. If a focal mass lesion is present one catheter should be placed in the pericontusional area and a second catheter may be inserted in tissue considered normal. Placement of catheter directly into the contusion is not recommended. In patients with diffuse injury there is no preference to the location, but a catheter is commonly placed in the right frontal region. Lactate-pyruvate (L/P) ratio, glucose, glycerol and glutamate remain the most useful markers of cerebral ischemia. Lactate-pyruvate (L/P) ratio could be normal or even low in early ischemia and this has to be kept in mind. Microdialysis continues to be used to evaluate the effects of therapeutic interventions on cerebral metabolism. Improvement in cerebral tissue metabolism following a period of 100% FiO2 supports the use of normobaric hyperoxia. Hlatky, et al. [10] evaluated the role of tissue monitoring in predicting unfavourable post-operative course following evacuation of acute subdural haematoma. They demonstrated significant difference in neuromonitoring parameters between the groups of patients who had complicated (intractable intracranial hypertension, deleayed traumatic injury) or uneventful post-operative period. There was no difference in initial radiological appearance, but dramatic difference in mortality between the groups. Thus tissue monitoring may serve as an indicator of evolving secondary injury and trigger further therapeutic activity. BISPECTRAL INDEX: (BIS)- MONITORING OF ANAESTHETIC DEPTH Several EEG parameters derived from the multifactorial processing are recommended for intraoperative on line monitoring of anaesthesia (hypnotic component) related changes in cerebral function. It is a dimensionless number between 0 and 100 that co-relates with the level of sedation and hypnosis. In awake patients, BIS is between 90 and 100 while complete suppression of cortical electrical activity results in a BIS of 0. Changing of anaesthesia depth is reflected in the BIS value. BIS recording in unconscious, brain damaged non- sedated patients can help as an outcome predictor of consciousness recovery. Intraoperative facial nerve monitoring for CP angle surgery can be done with low level of neuromuscular block (instead of avoid it) while anaesthesia is maintained with target-controlled infusion

Review Article

of Propofol and Fentanyl so that the BIS is kept between 40- 60. BIS monitoring as a guide to hypnotic component of anaesthesia can save significant cost of anaesthesia and help to find out anaesthetic cause of delayed recovery or otherwise. MONITORS OF FUNCTION Awake testing (continuous) Some operations may be performed under local or regional anaesthesia with the patient awake. The parts of the patients nervous system not anaesthetized may be examined while surgery is being performed. A good example is cerebral surgery for resection of seizure focus where the eloquent areas of cortical function can be defined prior to seizure focus resection, andneurophysiologic method which monitors specific neural pathways (but not all areas e.g speech), cannot provide variety of neural function tested by awake examination. Similarly, carotid endarterectomy conducted under regional block can detect effects of blood flow reduction to 25 mL/min/ 100 gm compared to EEG & SEP detecting changes when flow is reduced to 15 or 20 mL/min /100 gm. Wake-up Test (discontinuous) Intermittent neurological examination done intraopera-tively following a reversible surgical manipulation e.g. Harrington Rod placement for scoliosis that has potential to cause neurologic damage. Nothing is gained by awakening a patient to assess neurologic function if nothing can be done to correct the problem. Advances is surgical methods have extended the period of neural risk therefore a more continuous method of assessment is needed than a,one time wake up test, hence present controversy and loss of popularity of this test. Ankle clonus test A modification of the wake up test that does not require patient cooperation has been proposed. This test is based on the observation that in the early recovery from general anaesthesia, sustained ankle clonus is normally easy to elicit which is thought to be due to continued loss of cortical inhibitory function in the early phases of recovery from anaesthesia. In case of spinal cord injury during surgery of the spine, the reflex arc that produces clonus is interrupted and clonus cannot be elicited. In a study of 1121 patients, all six patients who subsequently developed neurological deficit failed to demonstrate clonus when anaesthesia was lightened. There were only 3 false positive results. This test may not be applicable with pre-existing neurologic dysfunction. It has lower risk than wake up test.
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NEUROPHYSIOLOGICAL MONITORING Electroencephalogram (EEG) is the spontaneous electrical activity of the brain as produced by inhibitory and excitatory post-synaptic potentials in the pyramidal layers of the cortex. The EEG is measured by electrode pairs on the scalp and represents comparative activity in the two cerebral regions immediately below the electrodes. Reduction of amplitude and frequency or abnormal distribution of activity of the EEG is consistent with ischemia, deepening anaesthesia and some other cause. It is indispensable for intraoperative mapping of seizure foci, very useful to warn potential ischemia during procedures involving vascular supply of brain (intracranial aneurysm, AVM and carotid endarterectomy (ICEA). Since vascular shunting has associated risks, stroke risk can be reduced 10 fold using selective shunting in CEA based on EEG monitoring. Evoked potentials are a measurement of electrical potentials evoked by a stimulus and allow assessment of a specific neural tract. The peaks and valleys are thought to arise from specific neural generators and therefore can be used to follow the response at various points along the stimulated tract. Selective application can assist in operative decision making so as to reduce, but not eliminate, neural complications. The most commonly utilized evoked potentials are those produced by stimulation of sensory system: Sensory evoked potentials (SEP). It is very useful in conditions like neuroma in situ to delineate neural structures, identification of sensory strip on the exposed sensory cortex, spine monitoring in scoliosis surgery, facial N. monitoring in acoustic neuroma. Somatosensory evoked potential (SSEP), is most widely used where a peripheral nerve e.g. posterior tibial, common peroneal, ulnar or median is stimulated and the neural response measured. The most common use is for monitoring spinal corrective surgery and is predictive of neural outcome. SSEP can also be used for monitoring the viability of the pathways as they travel through the brainstem e.g. posterior fossa surgery and cerebral cortex, such as ischemia, adequacy of collected blood flow during temporary vessel clipping, tolerance to deliberate hypotension and detection of vasospasm; during neuroradiological procedures embolization of AVMS, streptokinase dissolution of occluding blood clots. Other uses being monitoring of bladder & rectal sphinecter innervations during cauda equina procedures, assessment H & F reflex for selective dorsal rhizotomy to relieve leg spastively, peripheral nerve and plexus surgery, detect sciatic N injury with hip procedures, positioning related nerve compromise.
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Motor Tract monitoring by epidural or spinal stimulation has been useful. Pure motor tract monitoring is accomplished using motor cortex stimulation using transcranial electrical or magnetic stimulation and recorded as compound muscle action potentials (CMAP). CRANIAL NERVE MONITORING Most commonly used for posterior fossa surgery, mainly for VIII and VII nerves, though other cranial nerves can be monitored. Facial nerve monitoring is usually accomplished by placing closely placed bipolar recording electrodes in the orbicularis oris and occuli. The muscle (EMG) recording are presented visually and audibly. Hand held stimulatory probe can also be utilized in the operating field to locate the facial nerve. Monitoring of lower cranial nerves (IX, X, XI, XII) is important during resection of large low brainstem lesions where injury may lead to airway collapse and aspiration. Of particular recent interest has been monitoring of the vagal innervation of the larynx using electrodes placed in the false vocal cords, surface electrodes placed in the larynx or by a specially designed endotracheal tube with contacts on each lateral surface. Auditory Brainstem response (ABR) produced when sound delivered to the ear, activates the cochlea and measured as peaks produced by neural pathway of hearing. Cortical response to auditory stimulation can also be recorded over the auditory cortex. Visual evoked potentials (VEP) are produced by light stimulation of eyes and recorded over occipital cortex. Used for procedures near anterior visual pathways and optical pathways. Small stimulators made with contact lenses or scleral caps are used now with higher success rate.

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