Abstract
Cerebral microdialysis (CMD) allows bedside semicontinuous monitoring of patient brain extracellular fluid. Clinical indications of CMD monitoring are focused on the management of secondary cerebral and systemic insults in acute brain injury (ABI) patients [mainly, traumatic brain injury (TBI), subarachnoid hemorrhage, and intracerebral hemorrhage (ICH)], specifically to tailor several routine interventions—such as optimization of cerebral perfusion pressure, blood transfusion, glycemic control and oxygen therapy—in the individual patient. Using CMD as clinical research tool has greatly contributed to identify and better understand important post-injury mechanisms—such as energy dysfunction, posttraumatic glycolysis, post-aneurysmal early brain injury, cortical spreading depressions, and subclinical seizures. Main CMD metabolites (namely, lactate/pyruvate ratio, and glucose) can be used to monitor the brain response to specific interventions, to assess the extent of injury, and to inform about prognosis. Recent consensus statements have provided guidelines and recommendations for CMD monitoring in neurocritical care. Here, we summarize recent clinical investigation conducted in ABI patients, specifically focusing on the role of CMD to guide individualized intensive care therapy and to improve our understanding of the complex disease mechanisms occurring in the immediate phase following ABI. Promising brain biomarkers will also be described.
Highlights
Cerebral microdialysis (CMD) has progressively evolved from a tool for clinical research into an additional brain monitoring modality to guide neurointensive care [1, 2]
Tight (4–6 mM) vs. moderate (6.1–8 mM) glycemic control is associated with more episodes of low glucoseCMD
Barriers to the widespread implementation of CMD are numerous, including costs, human resources, and the complexity of the technique [1]. These barriers may explain why CMD monitoring is still not in use in the majority of centers, as judged by a recent National survey on multimodal monitoring conducted in the UK [116]
Summary
Cerebral microdialysis (CMD) has progressively evolved from a tool for clinical research into an additional brain monitoring modality to guide neurointensive care [1, 2]. This study stressed the importance of following dynamic trends over time of both CMD L/P ratio and glucose for the timely detection of secondary cerebral ischemic insults It confirmed the potential value of CMD biomarkers to avoid low CPP by adjusting CPP thresholds individually in comatose ABI patients [16, 41,42,43]. Non-convulsive seizures and pseudo-periodic discharges might amplify secondary cerebral damage in the setting of ABI: using an elegant approach combining CMD with surface and intracortical electro-encephalography, Vespa and colleagues recently established a mechanistic link between seizures and metabolic crisis [84] This study is another example of how CMD can be used to monitor complex and concealed mechanisms and to test the efficacy of future interventions aimed at targeting seizure suppression.
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