Division of Neurocritical Care, Departments of Neurology and Neurosurgery, University of Chicago Medical Center, 5841 S. Maryland Avenue, Chicago, IL, 60637, USA.
Division of Neurocritical Care, Department of Neurology and Rehabilitation Medicine, University of Cincinnati, Cincinnati, OH, USA.
Neurotherapeutics. 2023 Oct;20(6):1457-1471. doi: 10.1007/s13311-023-01411-2. Epub 2023 Jul 25.
Secondary brain injury after neurotrauma is comprised of a host of distinct, potentially concurrent and interacting mechanisms that may exacerbate primary brain insult. Multimodality neuromonitoring is a method of measuring multiple aspects of the brain in order to understand the signatures of these different pathomechanisms and to detect, treat, or prevent potentially reversible secondary brain injuries. The most studied invasive parameters include intracranial pressure (ICP), cerebral perfusion pressure (CPP), autoregulatory indices, brain tissue partial oxygen tension, and tissue energy and metabolism measures such as the lactate pyruvate ratio. Understanding the local metabolic state of brain tissue in order to infer pathology and develop appropriate management strategies is an area of active investigation. Several clinical trials are underway to define the role of brain tissue oxygenation monitoring and electrocorticography in conjunction with other multimodal neuromonitoring information, including ICP and CPP monitoring. Identifying an optimal CPP to guide individualized management of blood pressure and ICP has been shown to be feasible, but definitive clinical trial evidence is still needed. Future work is still needed to define and clinically correlate patterns that emerge from integrated measurements of metabolism, pressure, flow, oxygenation, and electrophysiology. Pathophysiologic targets and precise critical care management strategies to address their underlying causes promise to mitigate secondary injuries and hold the potential to improve patient outcome. Advancements in clinical trial design are poised to establish new standards for the use of multimodality neuromonitoring to guide individualized clinical care.
颅脑损伤后的继发性脑损伤由一系列不同的、潜在的并发和相互作用的机制组成，这些机制可能会加重原发性脑损伤。多模态神经监测是一种测量大脑多个方面的方法，目的是了解这些不同病理机制的特征，并检测、治疗或预防潜在的可逆转的继发性脑损伤。研究最多的有创参数包括颅内压（ICP）、脑灌注压（CPP）、自动调节指数、脑组织局部氧分压以及组织能量和代谢指标，如乳酸/丙酮酸比值。了解脑组织的局部代谢状态以推断病理并制定适当的管理策略是一个活跃的研究领域。目前正在进行几项临床试验，以确定脑组织氧监测和皮质电图与其他多模态神经监测信息（包括 ICP 和 CPP 监测）结合的作用。已经证明，确定最佳 CPP 以指导个体化血压和 ICP 管理是可行的，但仍需要明确的临床试验证据。未来仍需要定义和临床关联从代谢、压力、流量、氧合和电生理综合测量中得出的模式。针对潜在病因的病理生理靶点和精确的重症监护管理策略有望减轻继发性损伤，并有可能改善患者的预后。临床试验设计的进步有望为多模态神经监测在指导个体化临床治疗中的应用确立新标准。
