Neurological Complications and Noninvasive Multimodal Neuromonitoring in Critically Ill Mechanically Ventilated COVID-19 Patients

Battaglini, Denise; Santori, Gregorio; Chandraptham, Karthikka; Iannuzzi, Francesca; Bastianello, Matilde; Tarantino, Fabio; Ball, Lorenzo; Giacobbe, Daniele Roberto; Vena, Antonio; Bassetti, Matteo; Inglese, Matilde; Uccelli, Antonio; Rocco, Patrícia Rieken Macêdo; Patroniti, Nicolò; Brunetti, Iole; Pelosi, Paolo; Robba, Chiara

doi:10.3389/fneur.2020.602114

Cited by 48 publications

(68 citation statements)

References 44 publications

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“…In hospitalized COVID-19 patients, higher mCBV and lower vasoreactivity were observed than matched healthy volunteers 37 . Also, in a small recent study using cerebral ultrasound, eICP was higher and diastolic CBFV lower in COVID-19 patients developing neurological complications when compared to others 38 . The authors added also the estimation of ICP using the optic nerve sheath diameter measure (ONSD) measurement with cerebral ultrasound, which was not available in our study.…”

Section: Discussionmentioning

confidence: 72%

Cerebral Hemodynamics and Intracranial Compliance Impairment In Critically Ill COVID-19 Patients: A Pilot Study

Brasil

Taccone

WAHYS

et al. 2020

Preprint

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Introduction: One of the possible mechanisms by which the new coronavirus (SARS-Cov2) could induce brain damage is the impairment of cerebrovascular hemodynamics (CVH) and intracranial compliance (ICC), due to the elevation of intracranial pressure (ICP). The main objective of this study was to assess the presence of CVH and ICC alterations in patients with COVID-19 and evaluate their association with short-term clinical outcome. Methods: 50 consecutive critically ill COVID-19 patients were studied with transcranial Doppler (TCD) and a non-invasive monitoring of ICC. Subjects were included on ICU admission; CVH was evaluated using mean flow velocities in the middle cerebral arteries (mCBFV), pulsatility index (PI) and estimated cerebral perfusion pressure (eCPP), while ICC using the P2/P1 ratio of estimated ICP curve (B4C device). The primary composite outcome was unsuccessful weaning from respiratory support or death at day 7.Results: On the first assessment (n= 50), only P2/P1 (1.20 [1.00-1.28] vs. 1.00 [0.88-1.16]; p=0.03) and eICP (14 [11-25] vs. 11 [7-15] mmHg; p=0.01) were significantly higher among patients with UO than others. Patients with UO had a significantly higher CVH/ICC score (9 [8-12] vs. 6 [5-7]; p<0.001) than those with favorable outcome; the area under the receiver operating curve (AUROC) for CVH/ICC score to predict UO was 0.86 (95% CIs 0.75-0.97); a score > 8.5 had 63 (46-77)% sensitivity and 87 (62-97)% specificity to predict UO. For those patients undergoing a second assessment (n=29) after a median of 11 (5-31) days, all measured variables were similar between the two time-points. No differences in the measured variables between ICU non-survivors (n=30) and survivors were observed.Conclusions: ICCI and CVH disturbances are often present in COVID-19 severe illness and could accurately predict early poor outcome.

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Section: Discussionmentioning

confidence: 72%

Cerebral Hemodynamics and Intracranial Compliance Impairment In Critically Ill COVID-19 Patients: A Pilot Study

Brasil

Taccone

WAHYS

et al. 2020

Preprint

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“…The lung and brain are important organs to be monitored. COVID-19 patients often present with severe hypoxemia not responsive to conventional treatment and at the same time are at high risk of neurological complications [ 17 , 36 ]. In this context, the role of rescue therapies generally used to improve oxygenation and outcomes in conventional severe ARDS [ 37 – 39 ] has not been completely elucidated in COVID-19 [ 14 , 40 – 43 ].…”

Section: Discussionmentioning

confidence: 99%

“…The potential harmful effects of these therapies on cerebral hemodynamics have not been investigated. Although COVID-19 patients are not primarily brain-injured, a significant proportion of them experience neurological complications [ 36 , 46 , 47 ]; the pathophysiology of such complications in this cohort of patients is complex and probably multifactorial, including different mechanisms such as viral neurotropism, hypercoagulability, and brain–lung crosstalk [ 48 ], with cerebral hypoxemia [ 17 , 19 ] consequent to severe respiratory failure. The use of rescue therapies can further aggravate the delicate relationship between the brain and the lungs in these patients [ 49 – 54 ].…”

Section: Discussionmentioning

confidence: 99%

“…No data are available regarding the effect of these rescue therapies on cerebral hemodynamics, particularly on cerebral oxygenation. This latter point is of extreme importance, as neurological complications are common in mechanically ventilated critically ill patients with COVID-19 [ 17 , 18 ] and may lead to impaired cerebral hemodynamics [ 17 , 19 ]. Furthermore, respiratory rescue therapies may have detrimental effects on brain physiology, especially in the early phases after application, when the major hemodynamic and respiratory changes occur; therefore, their application in brain-injured patients outside of the COVID-19 pandemic is currently debated [ 20 – 22 ].…”

Section: Introductionmentioning

confidence: 99%

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Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

et al. 2021

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Background In COVID-19 patients with acute respiratory distress syndrome (ARDS), the effectiveness of ventilatory rescue strategies remains uncertain, with controversial efficacy on systemic oxygenation and no data available regarding cerebral oxygenation and hemodynamics. Methods This is a prospective observational study conducted at San Martino Policlinico Hospital, Genoa, Italy. We included adult COVID-19 patients who underwent at least one of the following rescue therapies: recruitment maneuvers (RMs), prone positioning (PP), inhaled nitric oxide (iNO), and extracorporeal carbon dioxide (CO2) removal (ECCO2R). Arterial blood gas values (oxygen saturation [SpO2], partial pressure of oxygen [PaO2] and of carbon dioxide [PaCO2]) and cerebral oxygenation (rSO2) were analyzed before (T0) and after (T1) the use of any of the aforementioned rescue therapies. The primary aim was to assess the early effects of different ventilatory rescue therapies on systemic and cerebral oxygenation. The secondary aim was to evaluate the correlation between systemic and cerebral oxygenation in COVID-19 patients. Results Forty-five rescue therapies were performed in 22 patients. The median [interquartile range] age of the population was 62 [57–69] years, and 18/22 [82%] were male. After RMs, no significant changes were observed in systemic PaO2 and PaCO2 values, but cerebral oxygenation decreased significantly (52 [51–54]% vs. 49 [47–50]%, p < 0.001). After PP, a significant increase was observed in PaO2 (from 62 [56–71] to 82 [76–87] mmHg, p = 0.005) and rSO2 (from 53 [52–54]% to 60 [59–64]%, p = 0.005). The use of iNO increased PaO2 (from 65 [67–73] to 72 [67–73] mmHg, p = 0.015) and rSO2 (from 53 [51–56]% to 57 [55–59]%, p = 0.007). The use of ECCO2R decreased PaO2 (from 75 [75–79] to 64 [60–70] mmHg, p = 0.009), with reduction of rSO2 values (59 [56–65]% vs. 56 [53–62]%, p = 0.002). In the whole population, a significant relationship was found between SpO2 and rSO2 (R = 0.62, p < 0.001) and between PaO2 and rSO2 (R0 0.54, p < 0.001). Conclusions Rescue therapies exert specific pathophysiological mechanisms, resulting in different effects on systemic and cerebral oxygenation in critically ill COVID-19 patients with ARDS. Cerebral and systemic oxygenation are correlated. The choice of rescue strategy to be adopted should take into account both lung and brain needs. Registration The study protocol was approved by the ethics review board (Comitato Etico Regione Liguria, protocol n. CER Liguria: 23/2020).

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“…In hospitalized COVID-19 patients higher mCBV and lower vasoreactivity were observed than in matched healthy volunteers 37 . Also, in a small recent study using cerebral ultrasound eICP was higher and diastolic CBFV lower in COVID-19 patients developing neurological complications when compared to others 38 . The authors also added the estimation of ICP using the optic nerve sheath diameter (ONSD) measurement with cerebral ultrasound, which was not available in our study.…”

Section: Discussionmentioning

confidence: 72%

Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill Covid-19 Patients: A Pilot Study

Brasil

Wayhs

Tomazini

et al. 2020

Preprint

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Introduction: One of the possible mechanisms by which the new coronavirus (SARS-Cov2) could induce brain damage is the impairment of cerebrovascular hemodynamics (CVH) and intracranial compliance (ICC) due to the elevation of intracranial pressure (ICP). The main objective of this study was to assess the presence of CVH and ICC alterations in patients with COVID-19 and evaluate their association with short-term clinical outcome.Methods: 50 consecutive critically ill COVID-19 patients were studied with transcranial Doppler (TCD) and a non-invasive monitoring of ICC. Subjects were included upon ICU admission; CVH was evaluated using mean flow velocities in the middle cerebral arteries (mCBFV), pulsatility index (PI) and estimated cerebral perfusion pressure (eCPP) while ICC was assessed by using the P2/P1 ratio of estimated ICP curve (B4C device). The primary composite outcome was unsuccessful weaning from respiratory support or death on day 7.Results: At the first assessment (n= 50) only P2/P1 (1.20 [1.00-1.28] vs. 1.00 [0.88-1.16]; p=0.03) and eICP (14 [11-25] vs. 11 [7-15] mmHg; p=0.01) were significantly higher among patients with unfavorable outcome (UO) than others. Patients with UO had a significantly higher CVH/ICC score (9 [8-12] vs. 6 [5-7]; p<0.001) than those with favorable outcome; the area under the receiver operating curve (AUROC) for CVH/ICC score to predict UO was 0.86 (95% CIs 0.75-0.97); a score > 8.5 had 63 (46-77)% sensitivity and 87 (62-97)% specificity to predict UO. For those patients undergoing a second assessment (n=29) after a median of 11 (5-31) days, all measured variables were similar between the two time-points. No differences in the measured variables between ICU non-survivors (n=30) and survivors were observed.Conclusions: ICCI and CVH disturbances are often present in COVID-19 severe illness and could accurately predict early poor outcome.

show abstract

Neurological Complications and Noninvasive Multimodal Neuromonitoring in Critically Ill Mechanically Ventilated COVID-19 Patients

Cited by 48 publications

References 44 publications

Cerebral Hemodynamics and Intracranial Compliance Impairment In Critically Ill COVID-19 Patients: A Pilot Study

Cerebral Hemodynamics and Intracranial Compliance Impairment In Critically Ill COVID-19 Patients: A Pilot Study

Early effects of ventilatory rescue therapies on systemic and cerebral oxygenation in mechanically ventilated COVID-19 patients with acute respiratory distress syndrome: a prospective observational study

Cerebral Hemodynamics and Intracranial Compliance Impairment in Critically Ill Covid-19 Patients: A Pilot Study

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