Multimodal Neuromonitoring (MMNM)

Multimodal Neuromonitoring: an Explorative Study in Neurocritical Care Patients

Theoretical Framework & Background

Cortical spreading depressions (CSD) and seizures, are crucial in the development of delayed cerebral ischemia and poor functional outcome in patients suffering from acute brain injuries such as subarachnoid hemorrhage. Multimodal neuromonitoring (MMNM) provides the unique possibility in the sedated and mechanically ventilated patients to record these electrophysiological phenomena and relate them to measures of cerebral ischemia and malperfusion. MMNM combines invasive (e.g. electrocorticography, cerebral microdialysis, brain tissue oxygenation) and noninvasive (e.g. neuroimaging, continuous EEG) techniques. Additionally, cerebral microdialysis can measure the unbound extracellular drug concentrations of sedatives, which potentially inhibit CSD and seizures in various degrees, beyond the blood-brain barrier without further interventions.

Hypotheses

1. Online multimodal neuromonitoring can accurately detect changes in neuronal metabolic demand and pathological neuronal bioelectrical changes in highly vulnerable brain tissue.
2. Online multimodal neuromonitoring can accurately detect the impact of pathological neuronal bioelectrical changes on metabolic demand in highly vulnerable brain tissue.
3. The occurrence and duration of pathological neuronal bioelectrical changes are dependent on sedatives and antiepileptic drug concentrations
4. The occurrence and duration of pathological neuronal bioelectrical changes have a negative impact on functional and neurological long-term patient outcome.
5. Simultaneous invasive and non-invasive multimodal neuromonitoring can identify a clear relationship of both methods regarding pathological neuronal bioelectrical changes and metabolic brain status.

Methods

Systematic analysis of MMNM measurements following standardized criteria and correlation of electrophysiological phenomena with cerebral metabolic changes in all included patients. In a second step neuroimaging, cerebral extracellular sedative drug concentrations and neurological functional outcome, will be correlated with both electrophysiologic and metabolic changes. Due to numerous high-resolution parameters, machine learning algorithms will be used to correlate comprehensive data on group and individual levels following a holistic approach.

Level of originality

Extensive, cutting edge diagnostic methods are used to get a better insight into the pathophysiology of electrophysiological and metabolic changes during the development of secondary brain damage. Due to the immense amount of high-resolution data, a computer-assisted evaluation will be applied to identify relationships in the development of secondary brain injury. For the first time systematic testing of several drug concentrations beyond the blood-brain barrier will be performed. With these combined methods, we will be able to develop new cerebroprotective treatment concepts on an individual basis.

Study Overview

• Status: Recruiting
• Conditions: Seizures; Traumatic Brain Injury; Subarachnoid Hemorrhage; Intracerebral Hemorrhage; Cortical Spreading Depolarization and Depression; Ictal-Interictal Continuum

• Study Type: Observational
• Enrollment (Anticipated): 100

Contacts and Locations

• Study Contact: Name: Johannes Herta, MD PhD; Phone Number: +43 (0)1 40400-25770; Email: johannes.herta@meduniwien.ac.at
• Study Contact Backup: Name: Johannes Koren, MD PhD; Phone Number: +43 (0)1 80110-2524; Email: johannes.koren@meduniwien.ac.at

Study Locations

• Austria
  • Vienna, Austria, 1090
    • Recruiting
    • Department of Neurosurgery, Medical University of Vienna
    • Contact: Johannes Herta, MD PhD; Phone Number: +43 (0)1 40400-25770; Email: johannes.herta@meduniwien.ac.at
    • Contact: Johannes Koren, MD PhD; Phone Number: +43 (0)1 80110-2524; Email: johannes.koren@meduniwien.ac.at

Participation Criteria

Eligibility Criteria

• Ages Eligible for Study: 18 years to 80 years (ADULT, OLDER_ADULT)
• Accepts Healthy Volunteers: N/A
• Genders Eligible for Study: All

• Sampling Method: Probability Sample

Study Population

Individuals between 18-80 years with poor grade aneurysmal SAH (World Federation Neurosurgical Societies >3), severe ICH (ICH Score >3) or severe TBI (Glasgow Coma Scale <9).

Description

Inclusion Criteria:

• Individuals between 18-80 years with poor grade aneurysmal SAH (World Federation Neurosurgical Societies >3), severe ICH (ICH Score >3) or severe TBI (Glasgow Coma Scale < 9). The diagnosis of SAH, ICH and TBI will be established by computed tomography (CT).
• Individuals that are unlikely to regain consciousness within the following 48 hours.
• Individuals that are expected to survive for the next 48 hours.

Exclusion Criteria:

• Individuals younger than 18 years old and older than 80 years.
• Pregnant women (documented via positive ß-HCG test).
• Patients, who do not want to participate in the study. As the patient is not able to consent prior to the study, information about the study details will be given to the patient in case of clinical improvement. The patient information sheet will be handed out.

Thereafter, the patient has the possibility to withdraw permission of study-participation.

Study Plan

How is the study designed?

What is the study measuring?

Primary Outcome Measures

Outcome Measure	Measure Description	Time Frame
Count of SD during electrocorticography	Count of cortical spreading depolarization (SD) during continuous electrocorticography	up to 21 days
Daily pattern duration of CSD during electrocorticography	Duration of cortical spreading depression (CSD) per hour during continuous electrocorticography	up to 21 days
Daily pattern duration of NCSE during electrocorticography	Duration of nonconvulsive status epilepticus (NCSE) per hour during continuous electrocorticography	up to 21 days
Daily pattern duration of RPPIIC during electrocorticography	Duration of rhythmic or periodic EEG patterns on the ictal-interictal continuum (RPPIIC) per hour during continuous electrocorticography	up to 21 days
Daily duration of metabolic crisis	Duration of metabolic crisis (defined as Lactate Pyruvate ratio [LPR] > 40 and lactate higher than 4 mmol/l) during continuous electrocorticography	up to 21 days
Daily duration of mitochondrial dysfunction	Duration of mitochondrial dysfunction (defined as LPR > 40, Pyruvate > 70 μmol/l and partial brain tissue oxygenation [PbtO2] > 20 mmHg) during continuous electrocorticography	up to 21 days
Daily duration of ischemia	Duration of ischemia (defined as PbtO2 < 15 mmHg and cerebral perfusion pressure [CPP] < 60 mmHg) during continuous electrocorticography	up to 21 days
Daily duration of elevated intracranial pressure (ICP)	Duration of elevated intracranial pressure (defined as ICP > 22 mmHg) during continuous electrocorticography	up to 21 days
Neuropharmacology Cmax)	Cmax of routinely used sedative drug concentrations in blood and brain (Esketamine, Midazolam and Propofol)	up to 21 days
Neuropharmacology (AUC)	AUC of routinely used sedative drug concentrations in blood and brain (Esketamine, Midazolam and Propofol)	up to 21 days
Neuropharmacology (t1/2)	t1/2 of routinely used sedative drug concentrations in blood and brain (Esketamine, Midazolam and Propofol)	up to 21 days
Neuroimaging	Absence or presence of hypoperfusion or ischemic infarctions in neuroimaging	up to 28 days
Functional patient outcome	modified Rankin Scale	up to 6 months

Collaborators and Investigators

• Sponsor: Medical University of Vienna
• Collaborators: Karl Landsteiner Institute for Clinical Epilepsy Research
• Investigators: Principal Investigator: Johannes Herta, MD PhD, Department of Neurosurgery, Medical University of Vienna

Study record dates

Study Major Dates

• Study Start (ACTUAL): December 1, 2020
• Primary Completion (ANTICIPATED): December 1, 2025
• Study Completion (ANTICIPATED): December 1, 2025

Study Registration Dates

• First Submitted: June 9, 2020
• First Submitted That Met QC Criteria: January 31, 2021
• First Posted (ACTUAL): February 3, 2021

Study Record Updates

• Last Update Posted (ACTUAL): February 3, 2021
• Last Update Submitted That Met QC Criteria: January 31, 2021
• Last Verified: January 1, 2021

More Information

Terms related to this study

• Keywords: Electrocorticography; Cerebral Microdialysis; Neuropharmacology; Multimodal Neuromonitoring
• Additional Relevant MeSH Terms: Pathologic Processes; Cardiovascular Diseases; Vascular Diseases; Cerebrovascular Disorders; Brain Diseases; Central Nervous System Diseases; Nervous System Diseases; Neurologic Manifestations; Wounds and Injuries; Craniocerebral Trauma; Trauma, Nervous System; Intracranial Hemorrhages; Brain Injuries; Hemorrhage; Brain Injuries, Traumatic; Seizures; Subarachnoid Hemorrhage; Cerebral Hemorrhage
• Other Study ID Numbers: MMNM01

Drug and device information, study documents

• Studies a U.S. FDA-regulated drug product: No
• Studies a U.S. FDA-regulated device product: No