Brain Cooling in Traumatic Brain Injury and Stroke
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1 Brain Cooling in Traumatic Brain Injury and Stroke Bridget Harris, PhD, RGN Clinical Research Specialist, NHS Lothian Research Fellow, University of Edinburgh
2 Content Therapeutic temperature reduction after acute cerebral insults - evidence and practice - normothermia, hypothermia Terminology and scope Systemic versus brain cooling why brain cooling? Methods of non-invasive brain cooling pros and cons Temperature measurement Effect of therapeutic brain cooling on temperature clinical studies Future directions
3 Terminology and scope Selective brain cooling vs therapeutic brain cooling terminology Therapeutic brain cooling methods Invasive neuroprotection during surgery e.g. antegrade cerebral perfusion for aortic arch surgery Non-invasive Nasal/pharyngeal cooling External head cooling Therapeutic brain cooling acute cerebral insults - global and focal normothermia, hypothermia
4 Evidence for therapeutic temperature reduction in acute global cerebral insults Comatose survivors of cardiac arrest (VF), neonatal hypoxic ischaemic injury therapeutic hypothermia reduces mortality, improves functional outcome (Arrich et al. Cochrane Database Syst Rev 2012;9:CD004128; Jacobs et al. Cochrane Database Syst Rev 2013;1:CD00331) In these conditions therapeutic hypothermia is recommended as part of standard care
5 Evidence for therapeutic temperature reduction in acute focal cerebral insults Traumatic brain injury (TBI), stroke experimental evidence improved outcome with normothermia and hypothermia multifactorial neuroprotective effects (early) prevention and reduction of secondary insults (Dietrich & Bramlett Prog Brain Res 2007;162:201-17; van der Worp et al. Brain 2007;130: ) human evidence increased temperature is common and associated with worse outcome - death and disability (e.g. Greer et al Stroke 39: ) insufficient evidence that therapeutic temperature modulation - normothermia or hypothermia - improves outcome (Saxena et al. 2008; Sydenham et al. 2009; den Hertog et al Cochrane Database Syst Rev; Lakhan & Pamplona Stroke Res Treat 2012:295906; Georgiou & Manara Br J Anaesth 2013;110:357-67) normothermia is standard practice +/- hypothermia for refractory raised intracranial pressure (Johnston et al. Resuscitation 2006;70:254-62; Thompson et al. J Neurosci Nurs 2007;39:151-62) shivering
6 Systemic cooling versus brain cooling why brain cooling? Systemic methods drugs (e.g. acetaminophen), cooling blankets/pads, intravenous cooling catheters side effects Brain cooling nasal/pharyngeal cooling and external head cooling rationale Brain cooling has fewer side-effects than systemic hypothermia e.g. infection some studies use body warming (Feigin et al. J Clin Neurosci 2002;9:502-7; Gluckman et al. Lancet;365:663-70; Harris et al. J Neurosurg 2009;110: ) Brain rather than body temperature is important in cerebral protection (Busto et al. J Cereb Blood Flow Metab 1987;7:729-38; Busto et al. Crit Care Med 1989;20:1113-4) Preferential cooling of cortices (external cooling)?of benefit (Wityk Crit Care Med 1994;8: ) Little evidence in humans (Harris et al. HTA 2012;16;1-175)
7 Methods of non-invasive brain cooling pros and cons Nasal/pharyngeal cooling induce heat loss from the upper airways by convection +/- evaporation e.g. nasal gas flow, nasal lavage conduction e.g. nasal or pharyngeal balloons External head cooling induce heat loss through the skull by convection +/- evaporation e.g. fanning, conduction e.g. circulating liquid cooling helmet (active), ice packs/frozen gel helmet (passive) Pros and cons
8 Temperature Temperature measurement sites Intracranial Tympanic Magnetic resonance spectroscopy Core body PA, oesophagus, bladder, rectum best proxy Effectiveness of brain cooling in reducing temperature (Harris et al. HTA 2012;16(45)1-175)
9 Summary of average temperature reduction with therapeutic cranial cooling (studies reporting temperature reduction achieved) Head cooling method Cooling duration Intracranial temp reduction (total cooled pts) Core body temp reduction (total cooled pts) Rhinochill (upper airways) (Andreas 2008, Busch 2010, Abou-Chebl 2011) Quickcool nasal balloons (Springborg et al 2013) Nasal airflow + head fanning (Harris 2007) Gel head and neck (Sovika) (Poli et al 2013) Circulating liquid head and neck (Wang 2004, Harris 2009, Gaida 2008, TraumaTec Neuro ICU study/miller 2009) 60 mins 1.4 C (n=11) 72 hr ~1 C (n=6) 30 mins 0.41 C (n=12) ~50 mins 0.36 C (n=11) 1 24 hr 1 2 C (n=34) C* (n=106) ~1 C (n=9) 0.32 C (n=12) 0.25 C (n=11) 0.8 C (n=6) * includes mean and median data, all other temperatures are mean reductions
10 Rhinochill Intranasal Cooling Device Benechill, Inc. USA
11 Mean temperature reductions during the 1-hour RhinoChill induction Mean temperature reductions during 1-hour cooling with RhinoChill ICT = intracranial temperature (Abou-Chebl et al. Stroke 2011;42:2164-9) Copyright American Heart Association
12 QuickCool nasal balloons QuickCool AB, Lund
13 Fig. 2 Median temperature in the cerebrum in the first 72 h of cooling. As indicated by the linear regression line a temperature level of 37 C was not reached within 72 h of cooling (y = x , R2 = 0.111, p < ) (n=6) Springborg et al. Neurocrit Care 2013; 18(3):400-5
14 Temperature difference o C Interventions: 1 = none; 2 = nasal airflow; 3 = head fanning; 4 = airflow plus head fanning 12 pts traumatic brain injury or subarachnoid haemorrhage Intracranial temperature reduction compared to baseline with: 1. no intervention 2. nasal airflow - twice minute volume ( 24 L) + 20ppm NO 3. bilateral head fanning (ambient air approximately 8 m s -1 ) 4. airflow plus fanning (Harris et al. Br J Anaesth 2007;98:93-9)
15 MedCool Device (Wandaller et al. Am J Emerg Med 2009;27:460-5)
16 Forced convective device - soft, fabric helmet (Wass et al. J Cardiothorac Vasc Anesth 2013;27: )
17 CoolSystem Discrete Cerebral Hypothermia Device (Harris et al. J Neurosurg 2009;110: )
18 12 pts traumatic brain injury 12 head cooled, 13 controls Mean intracranial temperatures in cooled (cap) vs not cooled (no cap) After 24 hours, cooled group intracranial temperature 1.2 C lower than controls (Harris et al. J Neurosurg ; )
19 Sovika head and neck cooling device (Sovika GmbH) (Poli et al. Stroke 2013;44:708-13)
20 Brain, bladder, and tympanic temperatures stroke patients Copyright American Heart Association (Poli et al. Stroke 2013;44:708-13)
21 Future directions Non-invasive methods of measuring intracranial temperature continuous measurement Device development Higher quality studies temp reporting, outcome complications of cranial cooling vs systemic cooling cranial cooling to reduce intracranial pressure Standardardised terminology for therapeutic cranial cooling and methods
22 Thank you Systematic review of head cooling in adults after traumatic brain injury and stroke Harris, Andrews, Murray, Forbes, Moseley Health Technology Assessment 2012;16(45):1-175 can be downloaded without charge from: Project funded by the UK National Institute for Health Research Health Technology Assessment Programme, project number
Systematic review of head cooling in adults after traumatic brain injury and stroke
Health Technology Assessment 2012; Vol. 16: No. 45 ISSN 1366-5278 Systematic review of head cooling in adults after traumatic brain injury and stroke B Harris, PJD Andrews, GD Murray, J Forbes and O Moseley
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