My Love Affair with Multimodal Monitoring

My attitude about multimodal monitoring changed recently when I was asked to write a review article summarizing its use in the management of TBI. Having been involved rather intimately with this field, I can summarize the past decades as ones where my passion outpaced the promise. I kept thinking that with the right monitoring modalities and a way to aggregate the data to see the big picture of brain function, the field would explode. But that explosion, year after year, was more of a pop gun than the hockey stick growth people were predicting. 

Parents don’t see the growth in the kids they see every day, but when they look at pictures, a mark on the wall, or buy new clothes, the change becomes apparent. It was the same with multimodal monitoring. Early papers were more on the tools and not the trade. They explained the use of ICP, TCD, EEG, PbtO2, and not much on how they are combined to manage the patient. Two big TBI trials, CENTER-TBI and TRACK-TBI, looked at over 8,000 patients, unfortunately, with multimodal monitoring data in the back seat and imaging, biomarkers, and genomics driving the car (at least from my perspective). There were new definitions of end points and a new classification of injuries. So we saw some exciting work, but no big changes in monitoring.  

But by stepping back and taking a deep dive into the past few years, I see a different picture now. Ongoing trials are urging us to pay attention to multimodal monitoring…COGITATE with individualized CPP management (CPPopt) and BOOST comparing management strategies with and without a multimodal approach. We also saw a call to action to minimize the nihilism in the withdrawal of life-sustaining treatment, with the recommendation that prognostication be multimodal. A significant change I’m seeing is the rise of interest in spreading depolarizations and their role in neuroworsening. Of note are the efforts to identify SDs from scalp EEG recordings, which will open this monitoring modality to more patients. The use of advanced analytics and AI is now pervasive in the TBI literature. For new gadgets, there are centers working on “NIRS on steroids” in the form of diffuse correlation spectroscopy (DCS), which provides a non-invasive tool to more accurately monitor cerebral perfusion and likely a host of other metrics, including ICP. The basic trends I noted in the review were (1) a shift to personalized medicine, (2) data integration and AI to tease out insights from the data, and (3) the development of new non-invasive technology.  

So my pathologic passion for this field is now supported by the excitement I see in recent work, and it’s heartening to see a lot of the work is by a younger generation, most of whom share the same passion. I see their excitement at meetings and through publications and on a daily basis in the Neuromonitoring Analytics Discord server that Ethan Moyer started. Ideas get bounced around and developed at a dizzying pace. I urge you to join it. So as the sun begins to set on my contributions, it’s rising to a new level with this next generation. I couldn’t be happier.