CEREBRAL

OXYGENATION
MONITORING
• CEREBRAL OXYMETRY
Jugular Bulb Oximetry
Near Infrared Spectroscopy
Brain Tissue Oxygen Monitoring
Introduction
 Why monitor cerebral oximetry?
• Cerebral ischemia-mismatch b/w cerebral oxygen supply
and demand
• By providing an indication of cerebral ischaemia, cerebral
oximetry may allow appropriate therapy to be given before
neurologic damage becomes permanent.
JUGULAR VENOUS OXIMETRY
HISTORY
• 1920s by Myerson et al.- sampled the jugular bulb
directly with a needle placed near the base of the
skull just below and anterior to the tip of the
mastoid process
• In 1953-Seldinger intermittent indirect sampling of
the jugular bulb via catheters
• late 1980s, fibreoptic catheters which could
continuously measure oxygen saturation
 ANATOMY

• The jugular bulb, a dilatation in the upper end of the IJV, is the
final common pathway for venous blood draining from the
cerebral hemispheres, cerebellum and brainstem.

• Jugular bulb contains the blood, drained out from both sides
of the brain, out of which around 70% is from the same
hemisphere and 30% is from the opposite hemisphere

• Jugular bulb oxygen saturation (SjvO2) reflects the balance

between brain supply and consumption of oxygen
Cerebral Monitoring: Jugular Venous Oximetry Randall M. Schell, MD, and Daniel J. Cole, MD Anesth Analg
2000;90:559–66
• SjvO2 monitoring accurately reflects global and hemispheric
cerebral oxygenation when the dominant jugular bulb is
cannulated

• To determine dominant side :

as seen on the cerebral angiogram

comparison of jugular foramen size using CT scan
Ultrasonography used to compare the size of veins
Higher rise in ICP following manual compression of IJV

Side with the greatest degree of pathology as determined by

CT scan
Right side in the case of diffuse injury
PHYSIOLOGY
• Jugular venous oxygen is an indirect assessment of cerebral oxygen
use.
• Simplistically, when demand exceeds supply, the brain extracts
greater oxygen, resulting in decreased jugular bulb oxygen saturation
Cerebral Monitoring: Jugular Venous Oximetry Randall M. Schell, MD, and Daniel J. Cole, MD Anesth Analg 2000;90:559–66
• The difference in oxygen content between arterial and jugular venous blood is
expressed by the term (CaO2 - CjvO2) or AjvDO2.
• AjvDO2 = CMRO2/CBF
• Normally, AjvDO2 is stable at 4–8 mL O2/100 mL blood.
• If CMRO2 remains constant, changes in AjvDO2 should reflect changes in CBF.
• If AjvDO2 = 4 mL O2/100 mL blood, it is assumed that oxygen supply is greater
than demand (i.e., luxuriant).
• An AjvO2 = 8 mL O2/100 mL blood suggests that demand is in excess of supply
(i.e., ischemia).
Insertion – Seldinger techniqe

RETROGRADE cannulation
Seldinger technique

4 French gauge double-lumen

catheters are available (Oximetrix
and Edslab II)
 Distance measured from the point of
insertion to the level of the mastoid process or until
resistance is met
Awake patient may note a sensation in the jaw or ear as
the catheter abuts the base of the skull, indicating that the
tip of the catheter is in the jugular bulb.
• usually about 15 cm
• The catheter is then pulled back 0.5–1.0 cm

Bhardwaj A et al. Comparison of outcome using propofol or desflurane for aneurysm neck clipping surgery following
sub arachnoid haemorrhage. J Neuroanaesth Crit Care 2015;2:155.
• The position of the catheter should be
confirmed by lateral cervical spine X-ray or an
AP chest X-ray
• The end of the catheter should lie
at the level of and just medial to the mastoid
bone above the lower border of C1.
• Fluoroscopy can also be used to confirm position
• Two catheters are currently available
- Edslab II (Baxter Healthcare)
- Oximetrix (Abbott Laboratories)
• size 4 French gauge double-lumen catheters
• Distal lumen - to aspirate blood for in vivo calibration while
the
• Other lumen - contains two optical fibres, one to transmit and
the other to receive light
• These diodes send red and near infra-red light, at 1 ms
intervals to blood passing through the jugular bulb where it
is absorbed, reflected and refracted.
• The reflected light from haemoglobin is detected by a
photoelectric sensor and used to calculate haemoglobin
oxygen saturation
SjVO2 measurement:
• Serial sampling : cheaper and allows calculation of arteriovenous content
difference in oxygen (AVDO2), glucose and lactate
• Rate of aspiration of blood for measurement should be <2 ml/min to avoid
contamination from extracranial vessels

• Continuous : Fibreoptic oxymetric catheters; require frequent calibration

SjVO2
• Normal Range : 55% to 75% (In a healthy brain with preserved
flow‑metabolism coupling)

• Levels < 55% suggest cerebral hypoperfusion with oxygen demand

exceeding supply, an increase in oxygen extraction or a reduction in oxygen
delivery which may be an early warning sign of ischaemia

• Levels > 85% indicate relative hyperaemia or decreased oxygen supply

(infarct)
Journal of Neuroanaesthesiology and Critical Care | Vol. 2 • Issue 3 • Sep-Dec 2015 |
• Chan KH, Dearden NM, Miller JD, et al. Multimodality monitoring as a guide to
treatment of intracranial hypertension after severe brain injury. Neurosurgery
1993;32:547–53.
 Hyperemia

Polycythemia

>80%

Hypothermia

Sedative drugs

Anaesthetic drugs

Cerebral infarction

Journal of Neuroanaesthesiology and Critical Care | Vol. 2 • Issue 3 • Sep-Dec 2015 |

 SjvO2-clinical applications –
TRAUMATIC BRAIN INJURY
• As a means to identify ischaemia, which may be due to either systemic or
intracranial causes
• Episodes of SjvO2 desaturation predict poor outcome after head injury*
• As a guide for optimal usage of hyperventilation without causing cerebral
hypoperfusion# (>25 mm Hg PaCO2)
• To guide administration of fluids and level of oxygenation and optimise the cerebral
perfusion pressure

• It is of limited value in monitoring patients with infratentorial injuries or lesions as

the brain stem and cerebellum contributes very little to the venous outflow from
the brain
 SjVO2 in TBI
Lactate oxygen index (LOI)

• to predict outcome in traumatic brain injury patients

• It is calculated by the formula :
LOI = −AVDL (mmol/lt) ×2.24/AVDO2 (ml/dl)
AVDL = Arterial to jugular difference for lactate
AVDO2 = Arterial to jugular difference in oxygen content

• Normal value → <0.03

• Values >0.08 are seen in patients with failing oxygen extraction, leading to failure of
aerobic metabolism and increased production of lactic acid in the brain especially
in the first 24 h after head injury.
Robertson et al. Cerebral arteriovenous oxygen difference as an estimate of cerebral blood flow in comatose
patients. J Neurosurg 1989;70:222‑30.
SjVO2 in Neurosurgery
• To help in deciding the appropriate MAP and PaCO2 values to ensure adequate
cerebral oxygenation.

Intracranial aneurysm surgery

• To determine the minimal blood pressure that should be maintained to avoid
hypoperfusion

• To measure LOI (lactate oxygen index).

• Intraoperative LOI >0.08 during surgery for aneurysm clipping has been associated
with a poor outcome
 SjVO2 in Cardiac Surgery

• To recognise episodes of SjVO2 desaturation during the period

of rewarming after hypothermic cardiopulmonary bypass and
thereby prevent incidence of post‑operative cognitive
dysfunction*

ROLE IN CARDIAC ARREST

• SjVO2 values are higher in the non‑survivors than the survivors
of cardiac arrest (values of 80% vs. 67%)
• Probably due to the inability of dead neurons to utilise the
supplied oxygen#
*Schell RM, Kern FH, Reves JG. The role of continuous jugular venous saturation monitoring
during cardiac surgery with cardiopulmonary bypass. Anesth Analg 1992;74:627‑9.
#Takasu A, Yagi K, Ishihara S, Okada Y. Combined continuous monitoring of systemic and
cerebral oxygen metabolism after cardiac arrest. Resuscitation 1995;29:189‑94.
 Research applications of SjVO2

• To evaluate the effect of various anaesthetic agents on CBF

• Study comparing propofol and desflurane in patients undergoing
clipping of aneurysmal neck after SAH
• Use of desflurane was associated with increase in SjVO2 values
indicating hyperaemia
• Values were maintained within physiological range with the use
of propofol indicating better flow‑metabolism coupling

Bhardwaj A et al. Comparison of outcome using propofol or desflurane for aneurysm neck clipping
surgery following sub arachnoid haemorrhage. J Neuroanaesth Crit Care 2015;2:155.
LIMITATIONS
NEAR INFRARED SPECTROSCOPY
INTRODUCTION
• NIRS - first described in 1977 by Franz Jöbsis
• He made 2 key observations regarding near-infrared (NIR) light
1. light in the NIR spectrum (700–950 nm) can traverse biological tissue
because of the relative transparency of tissue to light in this
wavelength range
2. several biological molecules, termed chromophores, have distinct
absorption spectra in the NIR

• CHROMOPHORES: - oxyhemoglobin (O2Hb)

- deoxyhemoglobin (HHb)
- cytochrome c oxidase (CCO)
PRINCIPLE
• NIRS is based on the transmission and absorption of NIR light
(700–950 nm) as it passes through tissue
• Light is generated at specific wavelengths typically by light-
emitting diodes, and is usually detected by silicon photodiodes
• The emitting and detecting devices are often referred to as the
optodes.
• In biological tissue: much more complex
• Chomophore concn still directly related to absorption
• SCATTERING- main contributor of attenuation
1. Light can be scattered away and doesn’t reach the detector
2. scattered multiple times so path length increases
• In the adult head, scattering attenuates NIR light to such an extent that it
cannot pass across the whole head;
• Therefore, reflectance spectroscopy, where the light source and detector are
placed on adjacent areas of the head, must be used
• All NIRS techniques rely on a measure of optical attenuation, which is
the total loss of light caused by absorption and scattering.
• Commercial devices generally use wavelengths between 700 nm and 850
nm where the absorption spectra of O2Hb and HHb are maximally
separated, and there is minimal overlap with that of water absorption
(980 nm).

W Tosh, FRCA, M Patteril, MD FRCA DipClinEdu (RCS),

Cerebral oximetry, BJA Education, Volume 16, Issue 12,
December 2016, Pages 417–421, 
https://doi.org/10.1093/bjaed/mkw024
 • Near Infra Red light (700-1000 nm) used to measure regional
cerebral tissue oxygen saturation (rSO2)

• rSO2 Normal Value : 60-80%

• Ischaemic threshold is estimated to be 47% saturation*

*Levy WJ, Levin S, Chance B. Near infrared measurement of cerebral oxygenation, correlation with
electroencephalographic ischaemia during ventricular fibrillation. Anesthesiology 1995; 83: 738–746.
 PROBE PLACEMENT
• The probes illuminate up to a volume of 10 ml of
hemispherical tissue.
• The radial depth will depend on the interoptode distance.
• The optodes are placed on one side of the forehead away from
the midline, cerebral venous sinuses and temporalis muscle
with an interrupted spacing of 4–7 cm.
• Trancutaneous measurement
• Depth of 2 cm and 1.5cc volume
• Mainly cortex-most susceptible area to ischemia with
limited reserve
• Normal value of rso2 or scto2 =65 -70%(variable)
rso2
SctO2
W Tosh, FRCA, M Patteril, MD FRCA DipClinEdu (RCS),
Cerebral oximetry, BJA Education, Volume 16, Issue 12,
December 2016, Pages 417–421, 
https://doi.org/10.1093/bjaed/mkw024
 NIRS - Clinical applications
CARDIAC SURGERY

• Coronary artery bypass surgery : a significant association was found between

prolonged cerebral desaturation and early cognitive decline, and also a three-fold
increased risk of prolonged hospital stay

• Active treatment of declining cerebral rSO2 values prevented prolonged cerebral

desaturations and was associated with a shorter intensive care unit length of stay
and a significantly reduced incidence of major organ morbidity or mortality

• Significant reduction in perioperative stroke rate, from 2.0% to 0.97%*

Slater JP, Guarino T, Stack J, et al. Cerebral oxygen desaturation predicts cognitive decline and longer
hospital stay after cardiac surgery. Ann Thorac Surg 2009; 87: 36–44
*Goldman S et al. Optimizing intraoperative cerebral oxygen delivery using noninvasive cerebral oximetry
decreases the incidence of stroke for cardiac surgical patients. Heart Surg Forum 2004; 7: E376–81
DEEP HYPOTHERMIC CIRCULATORY ARREST

• Moderate (25–30°C) and deep (25°C) hypothermia during

complex cardiac surgeries

• EEG becomes progressively attenuated below 25°C so NIRS

advocated as a means of detecting onset of cerebral ischemia

W Tosh, FRCA, M Patteril, MD FRCA DipClinEdu (RCS),

Cerebral oximetry, BJA Education, Volume 16, Issue 12,
December 2016, Pages 417–421, 
https://doi.org/10.1093/bjaed/mkw024
 CAROTID ENDARTERECTOMY

• Temporary cross-clamping of the ICA is an integral part of the surgery

and can produce brain ischaemia in patients with poor collateral flow
• The perioperative stroke rate after CEA can be as high as 5%*

• NIRS : simple; continuous measurement of frontal cortex oxygen

saturation. Sensitivity of 80% with a specificity of 82%

*Barnett HJ et al. Benefit of carotid endarterectomy in patients with symptomatic moderate or severe
stenosis. North American Symptomatic Carotid Endarterectomy Trial Collaborators. N Engl J Med
1998; 339: 1415–25
POST-CEA HYPERPERFUSION SYNDROME
• Impaired autoregulation with a rapid restoration of regional perfusion can
generate a hyperperfusion syndrome characterized by headache, brain
oedema, seizures, and in severe cases intracerebral haemorrhage

• Significant correlation between rSO2 values immediately after declamping

and changes in CBF was found
• For detecting patients at risk of developing hyperperfusion syndrome using
a cut-off value of 5% :
Sensitivity and specificity 100% and 86.4%, respectively,
Positive predictive value of 50% and a negative predictive value of 100%.
 NIRS AND HEAD INJURY

• The use of NIRS in the context of adult TBI is currently not widespread
• The variability in baseline saturation readings is greater in TBI due to
loss of normal cerebral vascular auto-regulation and cerebral
anatomy → the subsequent changes from this baseline are more
difficult to interpret
• Presence of haematomas further confound saturation signals

• Potential as a bedside screening tool in TBI under observation for the

development of secondary mass lesions (not a surrogate for CT)
LIMITATIONS
(i) Blood from an extracranial source can create
erroneously low measurement.
(ii) Electrosurgical equipment, that is, diathermy, can affect
the accuracy of measurement.
(iii) Cerebral oximeters only measure regional cerebral
oxygenation. Large areas of the brain remain
unmonitored.
(iv) Cerebral oximeters are unable to identify a cause for the
desaturation

W Tosh, FRCA, M Patteril, MD FRCA DipClinEdu (RCS),

Cerebral oximetry, BJA Education, Volume 16, Issue 12,
December 2016, Pages 417–421, 
https://doi.org/10.1093/bjaed/mkw024
W Tosh, FRCA, M Patteril, MD FRCA DipClinEdu (RCS),
Cerebral oximetry, BJA Education, Volume 16, Issue 12,
December 2016, Pages 417–421, 
https://doi.org/10.1093/bjaed/mkw024
Near-infrared spectroscopy as an index of brain and tissue Oxygenation
J. M. Murkin et al. British Journal of Anaesthesia 103 i3–i13 (2009)
BRAIN TISSUE OXYGEN
MONITORING
INTRODUCTION
• PbtO2 is a complex and dynamic variable resulting from the
interaction of all factors affecting cerebral oxygen delivery and
demand (oxygen metabolism), the relative proportion of arterial or
venous vessels in the region of interest, and tissue oxygen diffusion
gradients.
• PbtO2 is, therefore, best considered a biomarker of cellular function
rather than simply a monitor of hypoxia/ischemia.
 BRAIN TISSUE OXYGEN MONITORING
• first reported by Clark in 1956
• 2 commercially available sensors:
1. Licox sensor (GMS, Germany), which measures brain tissue oxygen only
2. Neurotrend sensor (Diametrics Medical, High Wycombe, UK), which measures brain
tissue oxygen, carbon dioxide and pH.
- Both devices can be used to measure brain temperature

• The polarographic electrodes, usually inserted into the brain via a single or triple-
lumen bolt fixed into the skull
• To measure oxygenation in the most vulnerable areas of brain, PbtO2 probes are often
placed in tissue immediately surrounding a hematoma/ contusion, or in appropriate
vascular territories in cases of aneurysmal SAH. Such precise placement can be
technically challenging and sometimes impossible
 Brain Tissue Oxygen Monitoring (LICOX)
polarographic electrochemical microsensor - oxygen
thermocouple - temperature
• Oxygen diffuses from the tissue through the
polyethylene wall of the catheter into its inner
electrolyte chamber.
• A current is generated by the transformation of oxygen
by the polarographic cathode, a negatively polarized
precious metal electrode, to hydroxide ions, which is
then displayed as PO2 and temperature values 1) polyethylene tube
diffusion membrane
2) polarographic gold
cathode
3) polarographic silver anode
4) cell filled with electrolyte
5) cerebral tissue
INDICATIONS
• PbtO2 monitoring is recommended in the management of severe TBI
• As a complement to TCD and radiological monitoring for the detection
of vasospasm in comatose SAH patients.
• It may also identify targets for optimal cerebral oxygenation in
comatose patients with ICH
• Selection of patients with refractory intracranial hypertension who
may benefit from surgical decompression.
• It is also used in some centers during surgery for intracranial
aneurysms and arteriovenous malformations.
• Normal brain PbtO2 - between 20 and 35mmHg
• Ischemic threshold - 10 to 15mmHg
• The BTF recommends the institution of brain resuscitation measures
when PbtO2 < 15 mmHg.