Near-Infrared Spectroscopy (NIRS) in Traumatic Brain Injury (TBI)

María Roldán, Panayiotis A Kyriacou, María Roldán, Panayiotis A Kyriacou

Abstract

Traumatic brain injury (TBI) occurs when a sudden trauma causes damage to the brain. TBI can result when the head suddenly and violently impacts an object or when an object pierces the skull and enters brain tissue. Secondary injuries after traumatic brain injury (TBI) can lead to impairments on cerebral oxygenation and autoregulation. Considering that secondary brain injuries often take place within the first hours after the trauma, noninvasive monitoring might be helpful in providing early information on the brain's condition. Near-infrared spectroscopy (NIRS) is an emerging noninvasive monitoring modality based on chromophore absorption of infrared light with the capability of monitoring perfusion of the brain. This review investigates the main applications of NIRS in TBI monitoring and presents a thorough revision of those applications on oxygenation and autoregulation monitoring. Databases such as PubMed, EMBASE, Web of Science, Scopus, and Cochrane library were utilized in identifying 72 publications spanning between 1977 and 2020 which were directly relevant to this review. The majority of the evidence found used NIRS for diagnosis applications, especially in oxygenation and autoregulation monitoring (59%). It was not surprising that nearly all the patients were male adults with severe trauma who were monitored mostly with continue wave NIRS or spatially resolved spectroscopy NIRS and an invasive monitoring device. In general, a high proportion of the assessed papers have concluded that NIRS could be a potential noninvasive technique for assessing TBI, despite the various methodological and technological limitations of NIRS.

Keywords: cerebral autoregulation; cerebral oxygenation; near infrared spectroscopy; traumatic brain injury.

Conflict of interest statement

The authors declare no conflict of interests.

Figures

Figure 1
Figure 1
Flowchart of the methodology used to include 72 out of 207 studies published until July 2020.
Figure 2
Figure 2
Global distribution of scientific articles that discussed the use of near-infrared spectroscopy (NIRS) technology in traumatic brain injury (TBI) monitoring until July 2020. The number of publications per country is indicated by the intensity of the color, with darker colors representing a higher number of articles than lighter colors.
Figure 3
Figure 3
Number of publications per year associating TBI with the various types of NIRS applications.
Figure 4
Figure 4
Percentage of diagnosis papers per subgroup according to the outcome measured: oxygenation, autoregulation, hematomas, and neurorehabilitation monitoring.
Figure 5
Figure 5
(a) Absorption coefficient spectra of oxyhemoglobin (HbO2) and deoxyhemoglobin (HHb). (b) The probabilistic trajectory of photons from the source to a detector of incident near-infrared light is described as a “banana shape” [38]. Figure modified from [39].
Figure 6
Figure 6
Schematic diagram of NIRS detection modes. (a) Continuous wave NIRS (CW-NIRS), (b) spatially resolved spectroscopy (SRS), (c) time-resolved spectroscopy (TD-NIRS), and (d) phase modulated spectroscopy (PMS). The figure also shows a representation of the photon path in tissues for each technique. S: source, D: detector. (Figure modified from [49]).
Figure 7
Figure 7
NIRS-derived regional tissue oxygen saturation (green probe) analyzes the oxygen concentration in cerebral microcirculation, which is predominantly from venous oxygenation. Jugular bulb venous saturation (blue probe) analyzes the remaining oxygen concentration that flows from the venous sinuses to the internal jugular vein. Both are indirect measurements of how much oxygen is being used by the brain. Brain tissue oxygenation tension (yellow probe) analyzes the dissolved oxygen within the cerebral plasma that diffuses across the blood brain barrier (BBB). (Figure modified from [57,58]).
Figure 8
Figure 8
Demographics of the evidence on NIRS-derived oxygenation in TBI.
Figure 9
Figure 9
Distribution of NIRS techniques used for oxygenation monitoring in TBI patients. Where continuous wave modified Beer–Lamber law (CW MBL), spatially resolved spectroscopy (SRS), phase modulated spectroscopy (PMS), and ultrasound-tagged near-infrared spectroscopy (UT-NIRS).
Figure 10
Figure 10
Comparisons found in the evidence on NIRS-derived oxygenation in TBI.
Figure 11
Figure 11
Cerebral autoregulation, where cerebral blood flow is maintained constant over a range of MAP/CPP. Out of the autoregulatory plateau, CBF becomes pressure-dependent and intracranial pressure dangerously rises (modified from [80,83,85,86]). Hypotension with disrupted cerebral autoregulation rapidly leads to cerebral ischemia, while hypertension above the autoregulatory threshold increases the risk of hyperemia.
Figure 12
Figure 12
Demographics of the evidence on NIRS-derived autoregulation in TBI.
Figure 13
Figure 13
Distribution of NIRS techniques used for autoregulation monitoring in TBI patients.
Figure 14
Figure 14
Comparisons found in the evidence on NIRS-derived autoregulation in TBI.
Figure 15
Figure 15
Main conclusions of NIRS-derived monitoring in TBI. Each author concluded with a positive (green) or negative (red) statements. In a few cases, authors reported positive results with some limitations (yellow).

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