Cerebral metabolic monitoring pathobiological processes

Excitotoxicity Brain microdialysis has been used to monitor excitatory amino acids after TBI but requires specialised equipment and does not give a continuous online measure and therefore lacks the vigilance required of a clinically useful monitor.

Inflammation Important mediators of the inflammatory response have been measured in microdialysate and detected in jugular venous (and arterial blood giving a transcranial gradient) and in CSF after TBI. Analysis of the concentration of these mediators requires offline assay and our understanding of these processes is not yet at a level where modification of therapy (or the processes themselves) is likely to be successful.

Therefore, to date there is no CMM available with sensitivity or specificity for an intermediate physiological variable that, if modified, improves outcome. Such a device would require subsequent testing in a prospective randomised controlled trial. Current clinical management protocols aim to optimise cerebral oxygen delivery and reduce secondary insults. Therefore, we should at least monitor the endpoints of such a strategy. Currently SjvO2 recording with bad-side PtiO2 monitoring is proven technology with limitations, but it is widely available and assesses the endpoint of current intensive care therapy after acute brain injury.

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