Introduction
The brain has been considered an index organ for global tissue perfusion because of
the physiological processes aimed at flow preservation to vital organs of the body[1].When
cerebral perfusion is compromised, other organs are likely inadequately perfused as
well. It would therefore be prudent to monitor cerebral perfusion based on the proposition
that interventions aimed at its preservation will likely result in adequate tissue
perfusion of the whole body and reduced complications related to ischemia of various
organs.
It is worth emphasizing the difference between tissue perfusion and tissue oxygen
supply. It is a consensus that the normal oxygen supply/demand ratio is important
to normal tissue metabolic physiology at the molecular level. Because oxygen demand
is largely related to perfusion, it is perfusion that remains the main focus of all
clinicians in the cardiac operating room[1].
Very brief periods of cerebral hypoperfusion occur frequently during cardiac surgery
due to a multitude of factors (reduced cardiac output, low pump flow, decreased perfusion
pressure, etc.) but are of minute clinical significance. It is prolonged or cumulative
hypoperfusion, particularly in watershed areas of the brain, undetected by standard
monitors such as arterial blood pressure or pulse oximetry, that leads to brain tissue
injury and adverse outcomes[2]. To date, no device has been developed that can reliably,
continuously and non-invasively monitor global cerebral tissue perfusion directly.
A number of existing monitors can indirectly assess regional cerebral perfusion and
provide information useful in managing cerebral blood flow and oxygen supply.
Cerebral oximetry
Cerebral tissue oximetry operates via measurement of hemoglobin saturation of the
mixed arterial, capillary and venous blood in superficial frontal lobe being illuminated
by near-infrared light. The number represents the ratio of the oxygenated hemoglob
in to total hemoglobin, with the frequently reported range of 50-80 and bilateral
(right and left) hemisphere difference of no more than 10 points. Desaturation below
50% or more than 20% below baseline, obtained in an awake, non-sedated patient breathing
room air, has been used as the threshold of intervention in cardiac patients. Previous
evidence shows that interventions aimed at maintaining cerebral saturation at baseline
correlate with reduced neuropsychological complications and decreased length of hospital
stay[2-4].
The benefit of the monitor is that it is non-invasive and as such poses virtually
no known harm to the patient. It is portable, easy to apply and operate as well as
interpret. The cost is moderate and can be justified by the beneficial outcome it
associates with. It is now considered by many experts in the field as a standard of
monitoring during cardiac surgery[2]. Given that both hemispheres are monitored, it
can differentiate between global and unilateral causes of hypoperfusion, such as head
position or unilateral vessel occlusion. Because the technology does not require pulsatile
flow, it offers an advantage during cardiopulmonary bypass or in patients with non-pulsatile
arterial flow (e.g. patients with left ventricular assist devices).
The limitations of the monitor are few but significant: first, it samples a small
area of regional tissue in the frontal lobe which is supplied by both anterior and
middle cerebral arteries (internal carotid artery), therefore excluding the portion
of the brain perfused by the posterior circulation. Second, the monitoring sensors
are applied on the scalp and despite efforts to reduce extracranial signal contamination,
a minor degree of contamination still exists. The sensors are sensitive to external
light as well as abnormalities in cranial tissue structure or thickness (skull defects
or space occupying lesions, frontal sinus pathology, scalp hematoma or severe edema).
Sensors should not be placed on shaved skin as hair follicles (particularly of dark
hair) absorb light and can significantly alter the monitor output. Good pad adherence
to the scalp is critical in obtaining a consistent value and moisture build-up under
the sensor over time may affect output.
Neurophysiological monitors
Various methods monitoring neuronal transmission have been evaluated for use in cardiac
surgery. From cortical activity monitors (raw and processed electroencephalogram)
to deeper structure assessment (various sensory and motor evoked potentials) all have
shown some benefit in detecting or confirming neuronal injury. The most common limiting
factor to the practical application of these methods is the need for specialized equipment,
personnel trained in correct data gathering and interpretation, as well as constant
vigilance to potential output changes[5-6].
Somatosensory evoked potentials have very limited application in cardiac surgery due
to their sensitivity to hypnotic effect of anesthetic drugs, body temperature, acid-base
status, oxygen content, flow pulsatility and others. All of the above fluctuate frequently
in the cardiac operating room, reducing the practicality of this monitoring modality.
Motor evoked potentials have proven useful in descending aortic reconstructive surgery,
but are subject to similar limitations as well as susceptibility to neuromuscular
blockade[5].
Electroencephalogram is the most commonly used monitor of neuronal activity in the
operating room. It has been shown to aid in early detection of cortical tissue oxygen
supply/demand imbalance. Unfortunately, EEG monitors are highly non-specific for ischemic
injury per se, as not every imbalance is related to variations in blood flow. Other
confounders may include non-convulsive seizure activity or prior sub-clinical traumatic
cortical injury for example[6].
With the development of bispectral index monitor (BIS), which simplifies the user
interface EEG display to a single number obtained from placing an adhesive pad on
the patient's forehead, the popularity of processed EEG has risen. BIS was initially
designed as a depth of anesthesia monitor to prevent awareness. Several studies have
since examined the effect of depth of anesthesia (measured by BIS) on post-operative
outcomes and found that EEG over-suppression (correlating to BIS of <40 for prolonged
periods of time) is related to adverse neurological outcomes as well as higher 1-year
mortality[7-8]. Whether this reflects a neurotoxic effect of anesthetic drugs or greater
susceptibility of already abnormal brains to anesthetics remains unclear[9]. However,
BIS monitoring can aid in maintaining the anesthetic depth at a level sufficient for
hypnosis without over-suppression[6]. In addition, four channel BIS pads for monitoring
bilateral frontal cortex are available. These offer an advantage of displaying differences
in EEG from right to left hemisphere, further aiding in interpreting cortical imbalance
in neuronal activity.
EEG can also be helpful in assessing brain activity during deep hypothermic circulatory
arrest. A flat line should be pursued, as that indicates neuronal quiescence. During
periods of rewarming, neuronal hyperactivity is undesirable as it implies high metabolic
demand which is not yet met by oxygen supply, due to temperature related vascular
dysfunction constricting blood flow to the brain[6].
The limitation to BIS application is signal contamination from external electrical
sources (electrocautery use in close proximity) as well as intrinsic electromyographic
activity. The latter can be easily eliminated by administration of muscle relaxants.
Transcranial Doppler ultrasound
Transcranial Doppler ultrasound (TCD) is typically used to monitor flow in the middle
cerebral artery, as it carries approximately 40% of the hemispheric blood flow. Because
Doppler shift measures velocity, not mass of blood carried through the vessel, the
flow of blood is an estimation based on a predefined artery size. Nomograms are available
that describe normal systolic and diastolic flow velocities[6].
During cardiac surgery, several important applications of TCD have been proven useful.
First, the determination of systolic and diastolic baselines prior to surgical manipulation
will allow for the development of an intervention threshold by the clinician. Generally,
a reduction of mean systolic velocity by 60% or absence of diastolic velocity is considered
signs of hypoperfusion. During non-pulsatile flow, a velocity reduction of 80% is
considered an ischemic threshold. Intraoperative changes in flow velocities can be
related to head position, cannulae position or insufficient pump flow/blood pressure[6,10].
Second, TCD is useful in monitoring efficacy of selective cerebral perfusion during
circulatory arrest, as it will detect both antegrade and retrograde flow in the middle
cerebral artery. Lastly, TCD has an ability to detect an embolic event, which appears
as high-intensity transient signals (HITS) on the spectral envelope display. Unfortunately,
HITS can easily be mistaken for artifact by an untrained eye. In addition, the device
is not capable of differentiating gaseous from particulate emboli. Maintaining constant
probe position during surgery is also a challenge, as it requires a band strapped
around the patient's head holding the probe covered in sterile sleeve in situ.
Summary
Despite their limitations, all the methods described above share one significant benefit:
they are non-invasive and portable. Combined together, they can provide answers to
complex questions related to preserving adequate brain perfusion during cardiac surgery.
For example, significant EEG signal suppression coupled with normal NIRS and TCD velocities
suggest depth of anesthesia as a culprit, not ischemia. In another example, low TCD
velocities during rewarming from hypothermic bypass coupled with relatively normal
NIRS and high activity EEG indicate cranial vessel vasoconstriction and uncoupling
of blood flow from cerebral metabolism. Because standard monitors correlate poorly
with neuromonitors, it seems intuitive to add monitors that will help protect the
most important organ in the body. The current literature, albeit not abundant, certainly
demonstrates favorable outcomes in patients subject to neuromonitoring during cardiac
surgery.