(1) Locating the Wolfson Brain Imaging Centre (providing functional MR, spectroscopy and PET imaging) adjacent to the Neurosciences Critical Care Unit supports many different studies of acute brain injury including randomised control trials. The radiopharmaceuticals laboratory is accredited with MHRA-GMP licences and generates the widest range of PET radiotracers available in the UK. Software developed for physiological brain monitoring is used by around 40 centres worldwide.
A novel approach has been introduced based on transcranial Doppler interrogation of compartmental compliances within the brain for non-invasive prediction of intracranial hypertension, cerebral vasospasm and carotid artery stenosis. Near Infrared Spectroscopy has been introduced for the continuous monitoring of cerebral autoregulation and hence individual optimisation of arterial blood pressure and brain protection during cardiopulmonary bypass and in pediatric neuro-intensive care. Novel studies of drug penetration, 13C labelled investigations of glucose, lactate and pyruvate utilisation and cytokines following brain injury have been carried out in association with PET and MR spectroscopy. These technologies show that multimodal, computer-supported, brain monitoring in acute brain injury can be used to optimize cerebral perfusion pressure for the individual patient, a concept which has already been taken up in the International Guidelines for the management of severe traumatic brain injury.
(2) The assessment of cerebrospinal fluid dynamics in patients suffering from hydrocephalus and idiopathic intracranial hypertension has improved the management of complex disorders. The 3-D topography of changes in white matter around the ventricles before and after shunting is being explored using diffusion-weighted MR techniques and correlated with cognitive function.
(3) Collaboration with the MRC Cognition and Brain Sciences Unit pioneered the study of awareness in coma using functional MR; to date, 5 of 54 patients have demonstrated responses that could not be detected on clinical assessment. This work has led to the refinement of Management Guidelines; and brain computer interfaces are being developed.
(4) Several phase III trials are in progress: chronic subdural haematoma randomised study of drains versus no drain; RESCUEicp decompressive craniectomy trial (www.RESCUEicp.com) involving 267 patients from 43 centres in 17 countries, the largest surgical trial for the management of head injury to date; STASH ' a multicentre placebo controlled trial of acute statin therapy following aneurysmal subarachnoid haemorrhage based on extensive phase I/II studies (midway through recruitment); and the SILVER trial of uncoated versus silver coated external ventricular drains in the prevention of infection has been completed and shows a significant benefit.
