follow-up cases

in research applications, brain4care allows the comparison of a new vital signal with the clinical picture of the patient in real time and for an unlimited time, in a totally non-invasive way, without pain or risks.

vps valve adjustment

Outpatient monitoring

application and context

hydrocephalus is a disease caused by abnormal accumulation of cerebrospinal fluid in the brain in one or more ventricular sinuses, causing a change in brain compliance. The clinical follow-up of this disease includes periodic evaluation of surgically implanted valve function in patients to regulate adequate CSF drainage and maintain central nervous system balance (VPS valve).

Without the brain4care method, valve adjustment is done by observing the clinical condition in a trial-and-error process until adequate flow is achieved. This process requires having the patient return to the office constantly and can take from weeks to months.

how brain4care contributes to the regulation or need to replace vps valves

brain4care’s non-invasive monitoring allows for the verification of the changes in the patient’s brain compliance in a few minutes.

After performing readings in the sitting and supine positions, it is possible to identify the improper flow or malfunction of the valve:

  • If the patient’s symptoms worsen when they are lying down, and the ICP curve is altered in this position, this is a sign that the valve is not providing the necessary flow
  • If the symptoms worsen when the patient is seated and the ICP curve changes in this position, this is a sign that the valve is draining more than necessary

main benefits and impacts

  • Monitoring can be performed in minutes, in various care settings, without causing pain or entailing risks to the patient
  • Allows the reduction of the time to reach the valve’s adequate flow from months to hours or days
  • Drastically reduces the need for patient and caregiver transport
  • Optimizes the office’s agenda by opening space to work on new cases
  • More safety and assertiveness in the surgical indication for shunt replacement

related scientific article

Evaluation of a non-invasive method for monitoring intracranial pressure in children and adolescents with hydrocephaly – Master’s Thesis
Matheus Fernando Manzolli Ballestero

Clinical case 1 – vps valve control

Outpatient monitoring

Patient with ventriculoperitoneal shunt (VPS) complaining of severe headaches.

The noninvasive intracranial pressure monitoring (NIICP) was requested by the doctor in charge for the case, for evaluation of the VPS and follow-up of the case, with a diagnostic hypothesis of alteration of the VPS drainage flow.

findings and medical conduct

first monitoring
Change in brain compliance (P2/P1 ratio > 0.8)

medical conduct

Adjustment of the CSF drain valve in the VPS to 10 cmH20

second monitoring
brain compliance within normal parameters (P2/P1 ratio < 0.8)

medical conduct

Keep the CSF drain valve in the VPS at 10 cmH20

outcome

Improvement of patient quality of life, since he stopped feeling pain and constantly going to the emergency room

clinical case 2 – vps valve gauging

patient follow-up

Young female, with a history of hydrocephalus, performed the installation procedure for the ventriculoperitoneal drainage valve approximately 1 year ago. She maintained a stable clinical situation during the entire period after the VPS was installed, she informed her doctor that she would be traveling, so she was asked to undergo non-invasive intracranial pressure monitoring (NIICP) to check the proper functioning of the valve.

findings and medical conduct

first monitoring
Brain compliance without changes (P2/P1 ratio < 0.8)

medical conduct

Patient cleared for travel.

outcome

Fast result without impacting the patient’s life, without exposure to the radiation of imaging tests and with reduced costs.

surgical procedures with extracorporeal circulation (ecc)

ICU patient follow-up

application and context
During surgeries, with the use of extracorporeal circulation, there is an interruption of cerebral blood flow for an average period of 6 to 7 minutes, which increases the risks of neurological sequelae, as this alters brain compliance. For the prevention of this type of sequelae, intensive care physicians make use of several measures in the postoperative period, known by the term neuroprotection.

How brain4care contributes to the reduction of postoperative neurological sequelae
brain4care’s non-invasive monitoring method is able to assist the intensive care physician in monitoring postoperative ICU patients, determining whether neuroprotection measures such as sedation and vasoactive drugs are playing the therapeutic role of normalizing brain compliance. This way, it is possible to define the best moment for extubation of the patient, reducing the risks of reversible neurological sequelae such as mild confusion and temporary loss of movement, and irreversible sequelae, such as paresis (reduction or absence of the ability to move a part or side of the body) and severe neurological sequelae (causing total or partial physical dependence on others).

main benefits and impacts

  • Ease of use of the non-invasive method by the bedside
  • The morphology of the intracranial pressure curve may be used as a marker to detect alteration in brain compliance and to detect intracranial hypertension.
  • From monitoring to reporting in minutes

related scientific article
Determinants of neurological complications in the use of extracorporeal circulation (ECC).
Natia de Freitas Barbosa; Danilo Martins Cardinelli; Flávia Falci Ercole
Federal University of Minas Gerais, Belo Horizonte, MG – Brazil

clinical case 1- surgical procedures with extracorporeal circulation (ecc)

ICU patient follow-up

Man, age 50, with a history of aortic aneurysm repair 2 years ago. Admitted for dissection of the aorta, with a surgical proposal for its correction. During the procedure, the patient underwent extracorporeal circulation for 82 minutes, with aortic clamping at 48 minutes of surgery and cerebral hypoflow for 6 minutes.

Surgical procedure occurred without any incident and, at the end, the patient was referred to the ICU, sedated, in mechanical ventilation with the use of vasoactive drugs.

Noninvasive intracranial pressure monitoring (NIICP) was requested to analyze the behavior of the intracranial pressure curve (ICP) morphology after a procedure that causes cerebral hypoperfusion and to confirm whether the neuroprotection measures were effective. The patient was monitored three times (in the immediate postoperative, first postoperative and second postoperative periods).

findings and medical conduct

first monitoring
Change in brain compliance (P2/P1 ratio = 1.08)

medical conduct

Maintain sedation and wait 24 hours for further monitoring

second monitoring
Change in cerebral compliance, P2> P1, with worsening in the P1/P2 ratio = 1.52

medical conduct

Optimization of the sedation scheme for neuroprotection

third monitoring
Cerebral compliance within the normal range with P1> P2 (P2/P1 ratio = 0.75)

medical conduct

Sedation withdrawal and patient extubation.

outcome

Extubation of the patient in the postoperative room, without neurological sequelae and with reduced length of stay in the ICU

clinical case 2- surgical procedures with extracorporeal circulation (ecc)

ICU patient follow-up

A 40-year-old man, diagnosed with Marfan’s Syndrome, with correction of aortic dissection for 9 years, was admitted with a diagnosis of tube endocarditis. The patient underwent the exchange of a valved tube plus coronary artery reimplants.
During the surgical procedure, he underwent extracorporeal circulation for 182 minutes, with aortic clamping at 112 minutes and cerebral hypoflow for 9 minutes.
After the procedure, he was referred to the ICU, intubated, in mechanical ventilation with vasoactive drugs. On the same day, he had a convulsive tonic-clonic seizure.
Non-invasive intracranial pressure monitoring (NIICP) was requested to monitor the effectiveness of neuroprotection measures. Overall, the patient was monitored four times (immediate postoperative, 1st postoperative, 2st postoperative, and 3rd postoperative periods).

findings and medical conduct

first monitoring
Change in brain compliance with P2> P1 (P2/P1 ratio = 1.3)

medical conduct

Optimization of the sedation scheme and prevention of secondary cerebral ischemia.

second monitoring
Performed in the first postoperative period. Maintained brain compliance changes with P2> P1, but with an improvement in the P2/P1 ratio (P2/P1 ratio = 1.21).

medical conduct

Optimization of the sedation scheme for neuroprotection.

third monitoring
Performed in the second postoperative period. Progression of the condition with improvement of brain compliance, however, P2>P1 (P2/P1 ratio = 0.95).

medical conduct

Maintain sedation and monitor again in 48 hours.

fourth monitoring
Performed in the postoperative period. Patient responded well to neuroprotection and the morphology of ICP is almost normalized, P2/P1 = 0.87.

medical conduct

Remove sedation and wait for extubation.

outcome

Patient was extubated on the fifth day of inpatient care and did not present neurological deficits.

neuroprotection after cardiac arrest

ICU patient follow-up

application and context
After cardiac arrest, there is an interruption of brain blood flow and, consequently, a change in cerebral compliance. The death rate of patients in this state can reach up to 80% and it is known that 8 out of 10 survivors will have neurological sequelae. For prevention of sequelae of this type, intensive care physicians use several post-stop measures known by the term neuroprotection, reducing the rate of survivors with sequelae to 2 out of 10 patients.

How brain4care contributes to the prevention of post-stop neurological sequelae
Braincare’s non-invasive monitoring method is able to assist the intensive care physician in monitoring post-stop ICU patients, determining whether neuroprotection measures such as sedation and vasoactive drugs are playing the therapeutic role of normalizing brain compliance. This way, it is possible to define the best moment for extubation of the patient, reducing the risks of reversible neurological sequelae such as mild confusion and temporary loss of movement, and irreversible sequelae, such as paresis (reduction or absence of the ability to move a part or side of the body) and severe neurological sequelae (causing total or partial physical dependence on others).

main benefits and impacts

  • Ease of use of the non-invasive method at bedside
  • The morphology of the intracranial pressure curve may be used as a marker to detect alteration in brain compliance and to detect intracranial hypertension
  • From monitoring to reporting in minutes

related scientific article
Determinants of neurological complications in the use of extracorporeal circulation (ECC).
Natia de Freitas Barbosa; Danilo Martins Cardinelli; Flávia Falci Ercole
Federal University of Minas Gerais, Belo Horizonte, MG – Brazil

clinical case 1 – neuroprotection after cardio-respiratory arrest

ICU patient follow-up

Man, age 64, with diagnosis of invasive tubular adenocarcinoma barely differentiated from sigmoid. Patient underwent electrosurgery with TT anastomosis without incident, referred to the bed after the anesthesia recovery period.

On the same day, after 1 hour in the recovery ward, he presented cardiorespiratory arrest in EAWP (electrical activity without pulse), with return of heart rhythm after 8 minutes of resuscitation maneuvers according to the ACLS (Advanced Cardiac Life Support) guidelines.

The patient, hemodynamically stable, was referred to the ICU and started neuroprotection measures for 24 hours: sedation and analgesia, temperature control (between 35-36ºC), glycemic control, PCO2 (partial pressure of carbon dioxide) between 35 and 40 mmHg, continuous capnography, hydration seeking VPS (mean arterial pressure) between 8 and 12 mmHg, AAP (Average Artery Pressure) between 90 and 100 mmHg, noninvasive monitoring of continuous cardiac output, oxygen saturation above 94%, plasma sodium above 140 mEq/L, continuous electroencephalogram, monitoring of NIICP (noninvasive intracranial pressure) prior to initiation of sedation and after complete withdrawal of sedation. The monitoring of NIICP was requested to verify whether the neuroprotection measures were effective to reduce possible brain damages caused by the cardiac arrest.

findings and medical conduct

first monitoring
Change in brain compliance (P2/P1 ratio = 1.46)

medical conduct

Initiate sedation and other neuroprotection measures according to medical prescription.

second monitoring
Brain compliance without changes (P2/P1 ratio = 0.64).

medical conduct

Initiate withdrawal of sedation for extubation.

outcome

Extubation of the patient in the postoperative room, without neurological sequelae and with reduced length of stay in the ICU.