Evoked potentials in the ICU.
The most informative neurophysiological techniques available in the neurosurgical intensive care unit are electroencephalograph and somatosensory evoked potentials. Such tools, which give an evaluation of cerebral function in comatose patients, support clinical evaluation and are complementary to neuroimaging. They serve both diagnostic/prognostic and monitoring purposes. While for the former, discontinuous monitoring is sufficient, for the latter, to obtain increased clinical impact, continuous monitoring is necessary. To perform and interpret these examinations in the neurosurgical intensive care unit, both the technician and the neurophysiologist need specific training in the intensive care field. There is sufficient evidence to show that somatosensory evoked potentials are the best single indicator of early prognosis in traumatic and hypoxic-ischaemic coma compared to the Glasgow Coma Score, computed tomography scan and electroencephalograph. Indeed, somatosensory evoked potentials should always be combined with clinical examination to determine the prognosis of coma. Despite widespread use of somatosensory evoked potentials and their prognostic utility in acute brain injury, few studies exist on continuous somatosensory evoked potential monitoring in the intensive care unit. We carried out a pilot study of continuous electroencephalograph-somatosensory evoked potential monitoring in the neurosurgical intensive care unit (traumatic brain injury and intracranial haemorrhage, Glasgow Coma Score <9, intracranial pressure monitoring). All patients stable from a clinical and computed tomography scan point of view showed no significant somatosensory evoked potential modifications, while in the case of clinical deterioration (23%), somatosensory evoked potentials always showed significant modifications. While somatosensory evoked potentials correlated with short-term outcome, intracranial pressure showed a poor correlation. We believe neurophysiological monitoring is an ideal complement to the other parameters monitored in the neurosurgical intensive care unit. Whereas intracranial pressure is simply a pressure index, electroencephalograph-somatosensory evoked potential monitoring reflects to what extent cerebral parenchyma still remains metabolically active during acute brain injury.
Amantini
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University of Florence, Azienda Ospedaliero-Universitaria Careggi, Department of Neurological and Psychiatric Sciences, UO Neurophysiopatology, Firenze, Italy. amantini@unifi.it
Amadori
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Fossi
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D001930:Brain Injuries / Q000175:diagnosis / Q000628:therapy; D003422:Critical Care; D004569:Electroencephalography / Q000379:methods; D005073:Evoked Potentials, Somatosensory; D015600:Glasgow Coma Scale; D006801:Humans; D020925:Hypoxia-Ischemia, Brain / Q000473:pathology; D007362:Intensive Care Units; D007427:Intracranial Pressure; D008991:Monitoring, Physiologic / Q000295:instrumentation / Q000379:methods*; D009482:Neurophysiology; D009493:Neurosurgery / Q000379:methods*; D014057:Tomography, X-Ray Computed; D016896:Treatment Outcome