Jones Salazar, Schwartzbauer Gary, Jia Xiaofeng
Department of Neurosurgery, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
R Adams Cowley Shock Trauma Center, University of Maryland School of Medicine, Baltimore, MD 21201, USA.
Int J Mol Sci. 2016 Dec 27;18(1):43. doi: 10.3390/ijms18010043.
Assessment of neurologic injury and the evolution of severe neurologic injury is limited in comatose or critically ill patients that lack a reliable neurologic examination. For common yet severe pathologies such as the comatose state after cardiac arrest, aneurysmal subarachnoid hemorrhage (aSAH), and severe traumatic brain injury (TBI), critical medical decisions are made on the basis of the neurologic injury. Decisions regarding active intensive care management, need for neurosurgical intervention, and withdrawal of care, depend on a reliable, high-quality assessment of the true state of neurologic injury, and have traditionally relied on limited assessments such as intracranial pressure monitoring and electroencephalogram. However, even within TBI there exists a spectrum of disease that is likely not captured by such limited monitoring and thus a more directed effort towards obtaining a more robust biophysical signature of the individual patient must be undertaken. In this review, multimodal monitoring including the most promising serum markers of neuronal injury, cerebral microdialysis, brain tissue oxygenation, and pressure reactivity index to access brain microenvironment will be discussed with their utility among specific pathologies that may help determine a more complete picture of the neurologic injury state for active intensive care management and long-term outcomes. Goal-directed therapy guided by a multi-modality approach appears to be superior to standard intracranial pressure (ICP) guided therapy and should be explored further across multiple pathologies. Future directions including the application of optogenetics to evaluate brain injury and recovery and even as an adjunct monitoring modality will also be discussed.
对于缺乏可靠神经学检查的昏迷或重症患者，神经损伤评估及严重神经损伤的演变情况受到限制。对于常见但严重的病症，如心脏骤停后的昏迷状态、动脉瘤性蛛网膜下腔出血（aSAH）和严重创伤性脑损伤（TBI），关键的医疗决策是基于神经损伤做出的。关于积极的重症监护管理、神经外科干预的必要性以及停止治疗的决策，取决于对神经损伤真实状态的可靠、高质量评估，并且传统上依赖于诸如颅内压监测和脑电图等有限的评估方法。然而，即使在TBI范围内，也存在一系列疾病，可能无法通过这种有限的监测来捕捉，因此必须做出更有针对性的努力，以获得个体患者更强大的生物物理特征。在本综述中，将讨论多模态监测，包括最有前景的神经元损伤血清标志物、脑微透析、脑组织氧合以及用于评估脑微环境的压力反应指数，以及它们在特定病症中的效用，这可能有助于更全面地了解神经损伤状态，以进行积极的重症监护管理和长期预后评估。以多模态方法为指导的目标导向治疗似乎优于标准颅内压（ICP）导向治疗，应在多种病症中进一步探索。还将讨论未来的方向，包括应用光遗传学评估脑损伤和恢复情况，甚至作为一种辅助监测方式。
