Intracranial multimodal monitoring for acute brain injury: a single institution review of current practices.

BACKGROUND

Critical care management of patients with severe acute brain injury has undergone tremendous advances. Neurosurgeons and neurointensivists have a large armamentarium of invasive monitoring devices available to help detect secondary brain injury and guide therapy. No consensus exists regarding patient specific selection of monitoring devices, the placement of devices in relation to injured brain tissue, or the preferred insertion technique. Here we review our experience in a consecutive series of acutely brain injured patients who underwent multimodality monitoring.

METHODS

Sixty-one patients admitted to the Neurological Intensive Care Unit underwent multimodality intracranial monitoring between January 2005 and October 2008. Patient demographics, hospital length of stay, types of monitoring devices and modalities monitored, insertion techniques, device placement location relative to injury, and complications are reported.

RESULTS

Monitored modalities included brain tissue oxygen (PbtO(2)) in 97% (N = 59), microdialysis (MD) in 79% (N = 48), intracranial electroencephalography in 31% (N = 19), brain temperature in 18% (N = 11), and cerebral blood flow in 11% (N = 7). On average, monitoring started within 2 days (0-8) of admission and was continued for 7 days (1-17). The majority of probes (56%; N = 35) were placed into patients with focal brain injuries, while in 43% N = 26 the injury was diffuse. Among those with focal injury, probe placement was categorized as peri-lesional in 46% (N = 16), and within a clot or infarct in 17% (N = 6). The most frequent complication of multimodality brain monitoring was device malfunction or dislodgement (43%; N = 26). Rates of hematoma and infection were 3 and 5%, respectively. Average NICU length of stay was 17 days (3-48) and 26% (N = 16) of patients were dead at discharge.

CONCLUSIONS

Collaboration among institutions is necessary to establish practice guidelines for the choice and placement of multimodal monitors. Further advancement in device technology is needed to improve insertion techniques, inter-device compatibility, and device durability. Multimodality data needs to be analyzed to determine the preferable device location.