title: Brainstem Monitoring in the Neurocritical Care Unit: A Rationale for Real-Time, Automated Neurophysiological Monitoring.
abstract: Patients with severe traumatic brain injury or large intracranial space-occupying lesions (spontaneous cerebral hemorrhage, infarction, or tumor) commonly present to the neurocritical care unit with an altered mental status. Many experience progressive stupor and coma from mass effects and transtentorial brain herniation compromising the ascending arousal (reticular activating) system. Yet, little progress has been made in the practicality of bedside, noninvasive, real-time, automated, neurophysiological brainstem, or cerebral hemispheric monitoring. In this critical review, we discuss the ascending arousal system, brain herniation, and shortcomings of our current management including the neurological exam, intracranial pressure monitoring, and neuroimaging. We present a rationale for the development of nurse-friendly-continuous, automated, and alarmed-evoked potential monitoring, based upon the clinical and experimental literature, advances in the prognostication of cerebral anoxia, and intraoperative neurophysiological monitoring.
authors.affiliation: Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA. jlstone4@gmail.com.|Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA. jlstone4@gmail.com.|Division of Neurosurgery, Department of Surgery, Cook County Stroger Hospital, Chicago, IL, USA. jlstone4@gmail.com.
authors.forename: James L
authors.initials: JL
authors.lastname: Stone
authors.affiliation: Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.
authors.forename: Julian E
authors.initials: JE
authors.lastname: Bailes
authors.affiliation: Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA.
authors.forename: Ahmed N
authors.initials: AN
authors.lastname: Hassan
authors.affiliation: Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.|Department of Neurosurgery, University of Florida, Gainesville, FL, USA.
authors.forename: Brian
authors.initials: B
authors.lastname: Sindelar
authors.affiliation: Department of Neurosurgery, NorthShore University HealthSystem, Evanston, IL, USA.
authors.forename: Vimal
authors.initials: V
authors.lastname: Patel
authors.affiliation: Departments of Neurology and Neurological Surgery, University of Illinois at Chicago, Chicago, IL, USA.
authors.forename: John
authors.initials: J
authors.lastname: Fino
mesh_terms: D020520:Brain Infarction / Q000175:diagnosis*; D000070642:Brain Injuries, Traumatic / Q000175:diagnosis*; D001932:Brain Neoplasms / Q000175:diagnosis*; D001933:Brain Stem / Q000503:physiopathology*; D002543:Cerebral Hemorrhage / Q000175:diagnosis*; D003422:Critical Care / Q000379:methods*; D006801:Humans; D064926:Neurophysiological Monitoring / Q000379:methods* / Q000592:standards
keywords: Ascending arousal system; Intracranial pressure; Intracranial space-occupying lesions; Motor evoked potentials; Neurocritical care unit; Neuromonitoring; Real-time, automated brainstem and cerebral monitoring; Severe traumatic brain injury; Somatosensory evoked potentials; Transtentorial herniation