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Article ; Online: Transcranial Ultrasound in the Neurocritical Care Unit.

Rajajee, Venkatakrishna

2024 Volume 34, Issue 2, Page(s) 191–202

Abstract: Ultrasound evaluation of the brain is performed through acoustic windows. Transcranial Doppler has long been used to monitor patients with subarachnoid hemorrhage for cerebral vasospasm. Transcranial color-coded sonography permits parenchymal B-mode ... ...

Abstract	Ultrasound evaluation of the brain is performed through acoustic windows. Transcranial Doppler has long been used to monitor patients with subarachnoid hemorrhage for cerebral vasospasm. Transcranial color-coded sonography permits parenchymal B-mode imaging and duplex evaluation. Transcranial ultrasound may also be used to assess the risk of delayed cerebral ischemia, screen patients for the presence of elevated intracranial pressure, confirm the diagnosis of brain death, measure midline shift, and detect ventriculomegaly. Transcranial ultrasound should be integrated with other point-of-care ultrasound techniques as an essential skill for the neurointensivist.
MeSH term(s)	Humans ; Subarachnoid Hemorrhage/diagnostic imaging ; Ultrasonography, Doppler, Transcranial/methods ; Brain Ischemia ; Vasospasm, Intracranial/diagnostic imaging ; Brain
Language	English
Publishing date	2024-02-13
Publishing country	United States
Document type	Journal Article ; Review
ZDB-ID	1314594-0
ISSN	1557-9867 ; 1052-5149
ISSN (online)	1557-9867
ISSN	1052-5149
DOI	10.1016/j.nic.2023.11.001
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Article ; Online: Noninvasive Intracranial Pressure Monitoring: Are We There Yet?

Rajajee, Venkatakrishna

Neurocritical care

2024

Abstract: There is an urgent unmet need for a reliable noninvasive tool to detect elevations in intracranial pressure (ICP) above guideline-recommended thresholds for treatment. Gold standard invasive ICP monitoring is unavailable in many settings, including ... ...

Abstract	There is an urgent unmet need for a reliable noninvasive tool to detect elevations in intracranial pressure (ICP) above guideline-recommended thresholds for treatment. Gold standard invasive ICP monitoring is unavailable in many settings, including resource-limited environments, and in situations such as liver failure in which coagulopathy increases the risk of invasive monitoring. Although a large number of noninvasive techniques have been evaluated, this article reviews the potential clinical role, if any, of the techniques that have undergone the most extensive evaluation and are already in clinical use. Elevations in ICP transmitted through the subarachnoid space result in distension of the optic nerve sheath. The optic nerve sheath diameter (ONSD) can be measured with ultrasound, and an ONSD threshold can be used to detect elevated ICP. Although many studies suggest this technique accurately detects elevated ICP, there is concern for risk of bias and variations in ONSD thresholds across studies that preclude routine use of this technique in clinical practice. Multiple transcranial Doppler techniques have been used to assess ICP, but the best studied are the pulsatility index and the Czosnyka method to estimate cerebral perfusion pressure and ICP. Although there is inconsistency in the literature, recent prospective studies, including an international multicenter study, suggest the estimated ICP technique has a high negative predictive value (> 95%) but a poor positive predictive value (≤ 30%). Quantitative pupillometry is a sensitive and objective method to assess pupillary size and reactivity. Proprietary indices have been developed to quantify the pupillary light response. Limited data suggest these quantitative measurements may be useful for the early detection of ICP elevation. No current noninvasive technology can replace invasive ICP monitoring. Where ICP monitoring is unavailable, multimodal noninvasive assessment may be useful. Further innovation and research are required to develop a reliable, continuous technique of noninvasive ICP assessment.
Language	English
Publishing date	2024-03-01
Publishing country	United States
Document type	Editorial
ZDB-ID	2381896-7
ISSN	1556-0961 ; 1541-6933
ISSN (online)	1556-0961
ISSN	1541-6933
DOI	10.1007/s12028-024-01951-1
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Article ; Online: Subarachnoid Hemorrhage Management Guidelines: Perspectives on Methodology and Clinical Guidance.

Rajajee, Venkatakrishna / Human, Theresa

Neurocritical care

2023 Volume 39, Issue 1, Page(s) 29–31

MeSH term(s)	Humans ; Subarachnoid Hemorrhage/therapy
Language	English
Publishing date	2023-05-18
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	2381896-7
ISSN	1556-0961 ; 1541-6933
ISSN (online)	1556-0961
ISSN	1541-6933
DOI	10.1007/s12028-023-01740-2
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Article ; Online: Brain Autopsy Findings in Adult Extracorporeal Membrane Oxygenation: Precipitating Event or Extracorporeal Membrane Oxygenation Treatment? Need More Data….

Napolitano, Lena M / Rajajee, Venkatakrishna

Critical care medicine

2020 Volume 48, Issue 6, Page(s) 936–937

MeSH term(s)	Adult ; Autopsy ; Brain/diagnostic imaging ; Brain Injuries ; Extracorporeal Membrane Oxygenation/adverse effects ; Humans ; Retrospective Studies
Language	English
Publishing date	2020-05-20
Publishing country	United States
Document type	Editorial ; Comment
ZDB-ID	197890-1
ISSN	1530-0293 ; 0090-3493
ISSN (online)	1530-0293
ISSN	0090-3493
DOI	10.1097/CCM.0000000000004319
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Zs.A 1261: Show issues

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Article ; Online: Use of a Novel Negative-Pressure Tent During Bedside Tracheostomy in COVID-19 Patients.

Rajajee, Venkatakrishna / Williamson, Craig A

Neurocritical care

2020 Volume 33, Issue 2, Page(s) 597–603

Abstract: Background: Many COVID-19 patients with neurological manifestations and respiratory failure remain dependent on mechanical ventilation and require tracheostomy, which is an aerosol generating procedure (AGP). The risk of SARS-CoV-2 transmission to ... ...

Abstract	Background: Many COVID-19 patients with neurological manifestations and respiratory failure remain dependent on mechanical ventilation and require tracheostomy, which is an aerosol generating procedure (AGP). The risk of SARS-CoV-2 transmission to healthcare staff during AGPs is well documented, and negative-pressure rooms are often unavailable. Innovative techniques to decrease risk to healthcare providers during AGPs are necessary. Our objective was to demonstrate the feasibility of percutaneous dilatational tracheostomy (PDT) performed using a novel prefabricated low-cost negative-pressure tent (AerosolVE). Methods: Retrospective review of consecutive PDT procedures performed by neurointensivists on intubated adult patients with COVID-19 using the AerosolVE tent during the pandemic under an innovative clinical care protocol. The AerosolVE negative-pressure tent consists of a clear plastic canopy with slits for hand access attached to a U-shaped base with air vents. Air within the tent is drawn through a high-efficiency particulate air filter and released outside. Preliminary testing during simulated AGPs demonstrated negligible escape of particulate matter beyond the tent. The main outcome measure was successful completion of PDT and bronchoscopy within the AerosolVE tent, without complications. Results: The patients were a 53-year-old man with multifocal ischemic stroke and acute respiratory distress syndrome (ARDS), 53-year-old woman with cerebellar hemorrhage and ARDS, and a 69-year-old man with ARDS. Pre-procedure FiO Conclusions: It is feasible to perform PDT on intubated COVID-19 patients using the AerosolVE negative-pressure tent. This is a promising low-cost device to decrease risk to healthcare providers during AGPs.
MeSH term(s)	Aged ; Betacoronavirus ; COVID-19 ; Coronavirus Infections/diagnosis ; Coronavirus Infections/prevention & control ; Coronavirus Infections/transmission ; Equipment Design ; Female ; Humans ; Infectious Disease Transmission, Patient-to-Professional/prevention & control ; Male ; Middle Aged ; Pandemics/prevention & control ; Pneumonia, Viral/diagnosis ; Pneumonia, Viral/prevention & control ; Pneumonia, Viral/transmission ; Pressure ; Protective Devices ; SARS-CoV-2 ; Tracheostomy/instrumentation
Keywords	covid19
Language	English
Publishing date	2020-08-07
Publishing country	United States
Document type	Case Reports ; Journal Article
ZDB-ID	2381896-7
ISSN	1556-0961 ; 1541-6933
ISSN (online)	1556-0961
ISSN	1541-6933
DOI	10.1007/s12028-020-01068-1
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Article ; Online: Measurement of Cerebral Metabolism Under Non-Chronic Hemodynamic Conditions.

Kripfgans, Oliver D / Pinter, Stephen Z / McCracken, Brendan M / Colmenero Mahmood, Carmen I / Rajajee, Venkatakrishna Krishna / Tiba, Hakam / Rubin, Jonathan M

Ultrasound in medicine & biology

2024

Abstract: Background: Blood flow to the brain is a critical physiological function and is useful to monitor in critical care settings. Despite that, a surrogate is most likely measured instead of actual blood flow. Such surrogates include velocity measurements in ...

Abstract	Background: Blood flow to the brain is a critical physiological function and is useful to monitor in critical care settings. Despite that, a surrogate is most likely measured instead of actual blood flow. Such surrogates include velocity measurements in the carotid artery and systemic blood pressure, even though true blood flow can actually be obtained using MRI and other modalities. Ultrasound is regularly used to measure blood flow and is, under certain conditions, able to provide quantitative volumetric blood flow in milliliters per minute. Unfortunately, most times the resulting flow data is not valid due to unmet assumptions (such as flow profile and angle correction). Color flow, acquired in three dimensions, has been shown to yield quantitative blood flow without any assumptions (3DVF). Methods: Here we are testing whether color flow can perform during physiological conditions common to severe injury. Specifically, we are simulating severe traumatic brain injury (epidural hematoma) as well as hemorrhagic shock with 50% blood loss. Blood flow was measured in the carotid artery of a cohort of 7 Yorkshire mix pigs (40-60 kg) using 3DVF (4D16L, LOGIQ 9, GE HealthCare, Milwaukee, WI, USA) and compared to an invasive flow meter (TS420, Transonic Systems Inc., Ithaca, NY, USA). Results: Six distinct physiological conditions were achieved: baseline, hematoma, baseline 2, hemorrhagic shock, hemorrhagic shock plus hematoma, and post-hemorrhage resuscitation. Mean cerebral oxygen extraction ratio varied from 40.6% ± 13.0% of baseline to a peak of 68.4% ± 15.6% during hemorrhagic shock. On average 3DVF estimated blood flow with a bias of -9.6% (-14.3% root mean squared error) relative to the invasive flow meter. No significant flow estimation error was detected during phases of flow reversal, that was seen in the carotid artery during traumatic conditions. The invasive flow meter showed a median error of -11.5% to 39.7%. Conclusions: Results suggest that absolute volumetric carotid blood flow to the brain can be obtained and potentially become a more specific biomarker related to cerebral hemodynamics than current surrogate markers.
Language	English
Publishing date	2024-02-29
Publishing country	England
Document type	Journal Article
ZDB-ID	186150-5
ISSN	1879-291X ; 0301-5629
ISSN (online)	1879-291X
ISSN	0301-5629
DOI	10.1016/j.ultrasmedbio.2024.02.002
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Zs.A 963: Show issues

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Article ; Online: Apnea Testing on Conventional Mechanical Ventilation During Brain Death Evaluation.

Merchant, Rameez Ali / Ahmad, Shahid Nafees / Haddix, Bradley / Williamson, Craig Andrew / Jacobs, Teresa Lee / Singh, Tarun Deep / Nguyen, Andrew M / Rajajee, Venkatakrishna

Neurocritical care

2024

Abstract: Introduction: The use of continuous positive airway pressure has been shown to improve the tolerance of the apnea test, a critical component of brain death evaluation. The ability to deactivate the apnea backup setting has made apnea testing possible ... ...

Abstract	Introduction: The use of continuous positive airway pressure has been shown to improve the tolerance of the apnea test, a critical component of brain death evaluation. The ability to deactivate the apnea backup setting has made apnea testing possible using several conventional mechanical ventilators. Our goal was to evaluate the safety and efficacy of apnea testing performed on mechanical ventilation, compared with the oxygen insufflation technique, for the determination of brain death. Methods: This was a retrospective study. In 2016, our institution approved a change in policy to permit apnea testing on conventional mechanical ventilation. We examined the records of consecutive adults who underwent apnea testing as part of the brain death evaluation process between 2016 and 2022. Using an apnea test technique was decided at the discretion of the attending physician. Outcomes were successful apnea test and the occurrence of patient instability during the test. This included oxygen desaturation (SpO2) < 90%, hypotension (mean arterial pressure < 65 mm Hg despite titration of vasopressor), cardiac arrhythmia, pneumothorax, and cardiac arrest. Results: Ninety-two adult patients underwent apnea testing during the study period: 58 (63%) with mechanical ventilation, 32 (35%) with oxygen insufflation, and 2 (2%) lacked documentation of technique. Apnea tests could not be completed successfully in 3 of 92 (3%) patients-two patients undergoing the oxygen insufflation technique (one patient with hypoxemia and one patient with hypotension) and one patient on mechanical ventilation (aborted for hemodynamic instability). Hypoxemia occurred in 4 of 32 (12.5%) patients with oxygen insufflation and in zero patients on mechanical ventilation (p = 0.01). Hypotension occurred during 3 of 58 (5%) tests with mechanical ventilation and 4 of 32 (12.5%) tests with oxygen insufflation (p = 0.24). In multivariate analysis, the use of oxygen insufflation was an independent predictor of patient instability during the apnea test (odds ratio 37.74, 95% confidence interval 2.74-520.14). Conclusions: Apnea testing on conventional mechanical ventilation is feasible and offers several potential advantages over other techniques.
Language	English
Publishing date	2024-04-25
Publishing country	United States
Document type	Journal Article
ZDB-ID	2381896-7
ISSN	1556-0961 ; 1541-6933
ISSN (online)	1556-0961
ISSN	1541-6933
DOI	10.1007/s12028-024-01990-8
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Article ; Online: Transcranial Color-Coded Sonography With Angle Correction As a Screening Tool for Raised Intracranial Pressure.

Rajajee, Venkatakrishna / Soroushmehr, Reza / Williamson, Craig A / Najarian, Kayvan / Ward, Kevin / Tiba, Hakam

Critical care explorations

2023 Volume 5, Issue 9, Page(s) e0953

Abstract: Objectives: Transcranial Doppler (TCD) has been evaluated as a noninvasive intracranial pressure (ICP) assessment tool. Correction for insonation angle, a potential source of error, with transcranial color-coded sonography (TCCS) has not previously been ...

Abstract	Objectives: Transcranial Doppler (TCD) has been evaluated as a noninvasive intracranial pressure (ICP) assessment tool. Correction for insonation angle, a potential source of error, with transcranial color-coded sonography (TCCS) has not previously been reported while evaluating ICP with TCD. Our objective was to study the accuracy of TCCS for detection of ICP elevation, with and without the use of angle correction. Design: Prospective study of diagnostic accuracy. Setting: Academic neurocritical care unit. Patients: Consecutive adults with invasive ICP monitors. Interventions: Ultrasound assessment with TCCS. Measurements and main results: End-diastolic velocity (EDV), time-averaged peak velocity (TAPV), and pulsatility index (PI) were measured in the bilateral middle cerebral arteries with and without angle correction. Concomitant mean arterial pressure (MAP) and ICP were recorded. Estimated cerebral perfusion pressure (CPP) was calculated as estimated CPP (CPPe) = MAP × (EDV/TAPV) + 14, and estimated ICP (ICPe) = MAP-CPPe. Sixty patients were enrolled and 55 underwent TCCS. Receiver operating characteristic curve analysis of ICPe for detection of invasive ICP greater than 22 mm Hg revealed area under the curve (AUC) 0.51 (0.37-0.64) without angle correction and 0.73 (0.58-0.84) with angle correction. The optimal threshold without angle correction was ICPe greater than 18 mm Hg with sensitivity 71% (29-96%) and specificity 28% (16-43%). With angle correction, the optimal threshold was ICPe greater than 21 mm Hg with sensitivity 100% (54-100%) and specificity 30% (17-46%). The AUC for PI was 0.61 (0.47-0.74) without angle correction and 0.70 (0.55-0.92) with angle correction. Conclusions: Angle correction improved the accuracy of TCCS for detection of elevated ICP. Sensitivity was high, as appropriate for a screening tool, but specificity remained low.
Language	English
Publishing date	2023-08-25
Publishing country	United States
Document type	Journal Article
ISSN	2639-8028
ISSN (online)	2639-8028
DOI	10.1097/CCE.0000000000000953
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Article ; Online: Use of a Novel Negative-Pressure Tent During Bedside Tracheostomy in COVID-19 Patients

Rajajee, Venkatakrishna / Williamson, Craig A.

Neurocritical Care

2020 Volume 33, Issue 2, Page(s) 597–603

Keywords	Critical Care and Intensive Care Medicine ; Clinical Neurology ; covid19
Language	English
Publisher	Springer Science and Business Media LLC
Publishing country	us
Document type	Article ; Online
ZDB-ID	2381896-7
ISSN	1556-0961 ; 1541-6933
ISSN (online)	1556-0961
ISSN	1541-6933
DOI	10.1007/s12028-020-01068-1
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Article: Screening Computed Tomography Angiography to Identify Patients at Low Risk for Delayed Cerebral Ischemia Following Aneurysmal Subarachnoid Hemorrhage.

Nguyen, Andrew M / Williamson, Craig A / Pandey, Aditya S / Sheehan, Kyle M / Rajajee, Venkatakrishna

Frontiers in neurology

2021 Volume 12, Page(s) 740241

Abstract: Introduction: ...

Abstract	Introduction:
Language	English
Publishing date	2021-11-12
Publishing country	Switzerland
Document type	Journal Article
ZDB-ID	2564214-5
ISSN	1664-2295
ISSN	1664-2295
DOI	10.3389/fneur.2021.740241
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