Case report
The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction
Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo
S. Matcan
, P. Sanabria Carretero, M. Gómez Rojo, L. Castro Parga, F. Reinoso-Barbero
Corresponding author
Departamento de Anestesiología, Reanimación y Cuidados Críticos, Hospital Universitario Infantil La Paz, Madrid, Spain
Read
Not available
Timeswas read the article
Total PDF
Total HTML
Share statistics
array:24 [ "pii" => "S2341192918300118" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.01.010" "estado" => "S300" "fechaPublicacion" => "2018-03-01" "aid" => "844" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "copyrightAnyo" => "2017" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:165-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "Traduccion" => array:1 [ "es" => array:19 [ "pii" => "S0034935617301664" "issn" => "00349356" "doi" => "10.1016/j.redar.2017.06.008" "estado" => "S300" "fechaPublicacion" => "2018-03-01" "aid" => "844" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Rev Esp Anestesiol Reanim. 2018;65:165-9" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 99 "formatos" => array:2 [ "HTML" => 72 "PDF" => 27 ] ] "es" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Caso clínico</span>" "titulo" => "Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo" "tienePdf" => "es" "tieneTextoCompleto" => "es" "tieneResumen" => array:2 [ 0 => "es" 1 => "en" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "169" ] ] "titulosAlternativos" => array:1 [ "en" => array:1 [ "titulo" => "The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction" ] ] "contieneResumen" => array:2 [ "es" => true "en" => true ] "contieneTextoCompleto" => array:1 [ "es" => true ] "contienePdf" => array:1 [ "es" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figura 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 587 "Ancho" => 1500 "Tamanyo" => 61770 ] ] "descripcion" => array:1 [ "es" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">TAC craneal (izquierda) y RM craneal (derecha) donde se aprecian señales compatibles de infarto agudo en la arteria cerebral izquierda media.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "S. Matcan, P. Sanabria Carretero, M. Gómez Rojo, L. Castro Parga, F. Reinoso-Barbero" "autores" => array:5 [ 0 => array:2 [ "nombre" => "S." "apellidos" => "Matcan" ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Sanabria Carretero" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Gómez Rojo" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Castro Parga" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Reinoso-Barbero" ] ] ] ] ] "idiomaDefecto" => "es" "Traduccion" => array:1 [ "en" => array:9 [ "pii" => "S2341192918300118" "doi" => "10.1016/j.redare.2018.01.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "en" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300118?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617301664?idApp=UINPBA00004N" "url" => "/00349356/0000006500000003/v2_201803170457/S0034935617301664/v2_201803170457/es/main.assets" ] ] "itemSiguiente" => array:19 [ "pii" => "S2341192918300179" "issn" => "23411929" "doi" => "10.1016/j.redare.2017.12.010" "estado" => "S300" "fechaPublicacion" => "2018-03-01" "aid" => "896" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:170-2" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:2 [ "total" => 1 "PDF" => 1 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Proposal for an algorithm for the management of the patient's airway after smoke inhalation" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "170" "paginaFinal" => "172" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Propuesta de algoritmo para el manejo de la vía aérea del paciente tras inhalación de humo" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Fig. 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2496 "Ancho" => 1583 "Tamanyo" => 224772 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Airway management algorithm for patients with suspected smoke inhalation injury.</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "P. Kot Baixauli, J.E. Morales Sarabia, L. Rovira Soriano, J. De Andrés Ibáñez" "autores" => array:4 [ 0 => array:2 [ "nombre" => "P." "apellidos" => "Kot Baixauli" ] 1 => array:2 [ "nombre" => "J.E." "apellidos" => "Morales Sarabia" ] 2 => array:2 [ "nombre" => "L." "apellidos" => "Rovira Soriano" ] 3 => array:2 [ "nombre" => "J." "apellidos" => "De Andrés Ibáñez" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617302943" "doi" => "10.1016/j.redar.2017.12.010" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617302943?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300179?idApp=UINPBA00004N" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300179/v3_201803240409/en/main.assets" ] "itemAnterior" => array:19 [ "pii" => "S2341192918300064" "issn" => "23411929" "doi" => "10.1016/j.redare.2018.01.005" "estado" => "S300" "fechaPublicacion" => "2018-03-01" "aid" => "842" "copyright" => "Sociedad Española de Anestesiología, Reanimación y Terapéutica del Dolor" "documento" => "simple-article" "crossmark" => 1 "subdocumento" => "crp" "cita" => "Revista Española de Anestesiología y Reanimación (English Version). 2018;65:160-4" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "en" => array:13 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "Can videolaryngoscopy be a first option in a patient with laryngeal amyloidosis?" "tienePdf" => "en" "tieneTextoCompleto" => "en" "tieneResumen" => array:2 [ 0 => "en" 1 => "es" ] "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "160" "paginaFinal" => "164" ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "¿Puede la videolaringoscopia ser una primera opción en paciente con amiloidosis laríngea?" ] ] "contieneResumen" => array:2 [ "en" => true "es" => true ] "contieneTextoCompleto" => array:1 [ "en" => true ] "contienePdf" => array:1 [ "en" => true ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 2287 "Ancho" => 1667 "Tamanyo" => 281829 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">(A) Computerised axial tomography of the neck showing submucosal amyloid infiltration in the subglottic area, resulting in stenosis of the laryngeal lumen. (B) Nuclear magnetic resonance image. Sagittal section, showing amyloid deposit (arrow).</p>" ] ] ] "autores" => array:1 [ 0 => array:2 [ "autoresLista" => "L. España Fuente, G. Mella Pérez, B. Laserna Cocina, J.L. González González" "autores" => array:4 [ 0 => array:2 [ "nombre" => "L." "apellidos" => "España Fuente" ] 1 => array:2 [ "nombre" => "G." "apellidos" => "Mella Pérez" ] 2 => array:2 [ "nombre" => "B." "apellidos" => "Laserna Cocina" ] 3 => array:2 [ "nombre" => "J.L." "apellidos" => "González González" ] ] ] ] ] "idiomaDefecto" => "en" "Traduccion" => array:1 [ "es" => array:9 [ "pii" => "S0034935617301640" "doi" => "10.1016/j.redar.2017.06.006" "estado" => "S300" "subdocumento" => "" "abierto" => array:3 [ "ES" => false "ES2" => false "LATM" => false ] "gratuito" => false "lecturas" => array:1 [ "total" => 0 ] "idiomaDefecto" => "es" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S0034935617301640?idApp=UINPBA00004N" ] ] "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300064?idApp=UINPBA00004N" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300064/v3_201803240409/en/main.assets" ] "en" => array:20 [ "idiomaDefecto" => true "cabecera" => "<span class="elsevierStyleTextfn">Case report</span>" "titulo" => "The importance of bilateral monitoring of cerebral oxygenation (NIRS): Clinical case of asymmetry during cardiopulmonary bypass secondary to previous cerebral infarction" "tieneTextoCompleto" => true "paginas" => array:1 [ 0 => array:2 [ "paginaInicial" => "165" "paginaFinal" => "169" ] ] "autores" => array:1 [ 0 => array:4 [ "autoresLista" => "S. Matcan, P. Sanabria Carretero, M. Gómez Rojo, L. Castro Parga, F. Reinoso-Barbero" "autores" => array:5 [ 0 => array:4 [ "nombre" => "S." "apellidos" => "Matcan" "email" => array:1 [ 0 => "snejana86@yahoo.com" ] "referencia" => array:1 [ 0 => array:2 [ "etiqueta" => "<span class="elsevierStyleSup">*</span>" "identificador" => "cor0005" ] ] ] 1 => array:2 [ "nombre" => "P." "apellidos" => "Sanabria Carretero" ] 2 => array:2 [ "nombre" => "M." "apellidos" => "Gómez Rojo" ] 3 => array:2 [ "nombre" => "L." "apellidos" => "Castro Parga" ] 4 => array:2 [ "nombre" => "F." "apellidos" => "Reinoso-Barbero" ] ] "afiliaciones" => array:1 [ 0 => array:2 [ "entidad" => "Departamento de Anestesiología, Reanimación y Cuidados Críticos, Hospital Universitario Infantil La Paz, Madrid, Spain" "identificador" => "aff0005" ] ] "correspondencia" => array:1 [ 0 => array:3 [ "identificador" => "cor0005" "etiqueta" => "⁎" "correspondencia" => "Corresponding author." ] ] ] ] "titulosAlternativos" => array:1 [ "es" => array:1 [ "titulo" => "Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo" ] ] "resumenGrafico" => array:2 [ "original" => 0 "multimedia" => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2015 "Ancho" => 2904 "Tamanyo" => 347038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Multimodal neuromonitoring NIRS-BIS. During CPB the NIRS shows some asymmetry between cerebral hemispheres (high oxygen consumption in the right hemisphere). SrO<span class="elsevierStyleInf">2</span>–Regional cerebral tissue oxygenation; CPB–cardiopulmonary bypass; MUF–modified ultrafiltration.</p>" ] ] ] "textoCompleto" => "<span class="elsevierStyleSections"><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0025">Introduction</span><p id="par0005" class="elsevierStylePara elsevierViewall">Cerebral oximetry monitoring based on near infrared spectroscopy (NIRS) technology determines regional cerebral oxygenation (SrO<span class="elsevierStyleInf">2</span>) in the absence of pulsatile perfusion, and analyzes the relationship between delivery and consumption of oxygen in the brain. It can detect cerebral hypoperfusion, hypoxemia, hypocapnia, low hematocrit, and other situations leading to reduced cerebral oxygen saturation. Bilateral monitoring of the frontal region, perfused by the anterior and middle cerebral arteries,<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">1</span></a> analyzes 1<span class="elsevierStyleHsp" style=""></span>cm<span class="elsevierStyleSup">3</span> of the cortex in each hemisphere. The value of SrO<span class="elsevierStyleInf">2</span> is mostly symmetrical (differences of around 10% are considered physiological). However, asymmetries are a result of different perfusion-oxygenation in each hemisphere which may be due to anatomical varieties in the Circle of Willis, cerebral embolism, excessive lateralization of the head during surgery, cannula malposition, selective cerebral perfusion, surgical clamping of the carotid artery or hyperperfusion syndrome after carotid revascularization.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–3</span></a> NIRS monitoring is widespread in cardiac surgery with cardiopulmonary bypass (CPB).<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–7</span></a> Scientific evidence establishes the relationship between declines in cerebral oxygenation and neurological disorders<a class="elsevierStyleCrossRefs" href="#bib0075"><span class="elsevierStyleSup">4,6,8,9</span></a> and between rapid management of the potential causes and improved outcomes regarding both morbidity and mortality.<a class="elsevierStyleCrossRefs" href="#bib0095"><span class="elsevierStyleSup">8,9</span></a> Reductions of over 20% of baseline or saturations under 50% have been proposed as threshold values related to neurological complications.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1–9</span></a></p><p id="par0010" class="elsevierStylePara elsevierViewall">We describe the first reported case of NIRS cerebral asymmetry during CPB in a child with a history of stroke and no baseline asymmetry. This shows the different consumption of oxygen in cerebral hemispheres in situations where oxygen transport may be compromised. We believe that this case supports the interpretation of NIRS records and contributes to the available evidence on this issue.</p></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0030">Clinical case</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 12-month old male child weighing 9<span class="elsevierStyleHsp" style=""></span>kg with a history of protein C deficiency and severe pulmonary valve stenosis with patent foramen ovale (PFO). The child had been previously treated when he was 2 and 4 months old by percutaneous valvuloplasty. In the second procedure, paradoxical cerebral embolism was detected with left middle cerebral artery stroke (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>) leading to severe right hemiparesis and focal epilepsy, which was treated with anticonvulsants (levetiracetam) and anticoagulants (acenocoumarol). At the time of the study, he presented an improvement of severe to mild hemiparesis, severe pulmonary valve stenosis, moderate tricuspid regurgitation and PFO. He underwent cardiac surgery with CPB for enlargement of the right ventricular outflow tract (RVOT), foramen ovale closure and tricuspid valvuloplasty. Monitoring consisted of femoral central venous pressure, femoral artery pressure, pulsioximetry, capnography, 5-lead EKG, ST analysis, nasopharyngeal and vesical temperature, analysis of blood gases, ions, acid-base balance, hematocrit, glucose, and diuresis.</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia><p id="par0020" class="elsevierStylePara elsevierViewall">Multimodal neuromonitoring consisted of bihemispheric transcranial cerebral oximetry based on NIRS technology (Invos, Covidien-Medtronic) and bispectral index (BIS). After aortic cannulation, CPB was initiated, and the circuit was primed with blood to achieve a 30% hematocrit, at an initial flow of 120<span class="elsevierStyleHsp" style=""></span>ml/kg/min, until 30<span class="elsevierStyleHsp" style=""></span>°C core temperature hypothermia was reached. The following NIRS changes were recorded in the different phases of surgery (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).<ul class="elsevierStyleList" id="lis0005"><li class="elsevierStyleListItem" id="lsti0005"><span class="elsevierStyleLabel">-</span><p id="par0025" class="elsevierStylePara elsevierViewall">At the beginning of surgery, mean arterial pressure (MAP) ranged between 55 and 65<span class="elsevierStyleHsp" style=""></span>mmHg and normothermia was noted, no asymmetries were detected regarding SrO<span class="elsevierStyleInf">2</span> in both hemispheres.</p></li><li class="elsevierStyleListItem" id="lsti0010"><span class="elsevierStyleLabel">-</span><p id="par0030" class="elsevierStylePara elsevierViewall">The first asymmetric reading occurred after cannulation of superior vena cava and aorta and the initiation of CPB. The greatest decline was recorded in the right hemisphere (healthy hemisphere, ipsilateral to hemiparesis) with an initial decline to 55% after cannulation (31% decrease from baseline) later decreasing to 50% (37% decrease from baseline) with the initiation of CPB. SrO<span class="elsevierStyleInf">2</span> on the left side only declined in 20% at this point. After ruling out cannula malposition, inadequate flow, or FiO<span class="elsevierStyleInf">2</span>, the asymmetry was attributed to low blood pressure and acute hemodilution. Since the right hemisphere already presented hypoxia criteria, phenylephrine 50<span class="elsevierStyleHsp" style=""></span>μg and propofol 30<span class="elsevierStyleHsp" style=""></span>mg were administered to stabilize the decline of SrO<span class="elsevierStyleInf">2</span>. At this point MAP was 50<span class="elsevierStyleHsp" style=""></span>mmHg and hematocrit 27%. The effect of propofol on the depth of anesthesia was observed in the BIS record (BIS under 10 with increased burst suppression rate).</p></li><li class="elsevierStyleListItem" id="lsti0015"><span class="elsevierStyleLabel">-</span><p id="par0035" class="elsevierStylePara elsevierViewall">During the remaining time on CPB, hypothermia reached 30<span class="elsevierStyleHsp" style=""></span>°C and asymmetry practically disappeared (differences under 10%).</p></li><li class="elsevierStyleListItem" id="lsti0020"><span class="elsevierStyleLabel">-</span><p id="par0040" class="elsevierStylePara elsevierViewall">During the rewarming period after weaning from CPB, the 12% asymmetry presented again, with a reduction of up to 37% in the right hemisphere and 20% in the left side compared with baseline. This was explained by the increased metabolic activity and higher cerebral oxygen consumption associated with the increasing temperature. The decline was stabilized with the administration of phenylephrine 50<span class="elsevierStyleHsp" style=""></span>μg and propofol 20<span class="elsevierStyleHsp" style=""></span>mg to reduce cerebral metabolism (BIS thus dropping under 10).</p></li><li class="elsevierStyleListItem" id="lsti0025"><span class="elsevierStyleLabel">-</span><p id="par0045" class="elsevierStylePara elsevierViewall">With the initiation of modified ultrafiltration (MUF) further asymmetries were observed, secondary to direct volemia theft from the aortic cannula (placed in the aortic arch) to the hemofilter and then reintroduced into the superior vena cava. This flow diversion can produce transient cerebral hypoperfusion. It is corrected by means of the hemoconcentrator effect of MUF itself (hematocrit rising to 40%).</p></li><li class="elsevierStyleListItem" id="lsti0030"><span class="elsevierStyleLabel">-</span><p id="par0050" class="elsevierStylePara elsevierViewall">At the end of MUF, SrO<span class="elsevierStyleInf">2</span> reached its baseline of 80% in the right side and 75% in the left side, with minimal asymmetry of 5%.</p></li></ul></p><elsevierMultimedia ident="fig0010"></elsevierMultimedia><p id="par0055" class="elsevierStylePara elsevierViewall">The patient was then transferred to the post-operative intensive care unit. He was weaned from mechanical ventilation 4<span class="elsevierStyleHsp" style=""></span>hours after his arrival. Anticonvulsant (levetiracetam) and anticoagulant (enoxaparin) therapies were immediately initiated and the post-operative course was satisfactory. No further neurological damage was observed in the following days.</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0035">Discussion</span><p id="par0060" class="elsevierStylePara elsevierViewall">Advances in the field of pediatric cardiac surgery have greatly improved morbidity and mortality in recent years. However, this kind of surgery implies a high risk for the development of neurological complications, which are sometimes not detected until years after the intervention, and usually result in behavioral disorders and learning impairment.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2,7,9,11</span></a></p><p id="par0065" class="elsevierStylePara elsevierViewall">Nevertheless, the main neurological risk is associated with the underlying heart disease and the immaturity of cerebral autoregulation in younger children. On the other hand, the intraoperative period entails an additional risk, due to prolonged bypass time, inflammatory response, embolic phenomena, hemodilution, anticoagulation and changes in the relationship between the consumption and delivery of oxygen in the brain during CPB.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2,10,11</span></a> During surgery, the critical points are: surgical dissection, cannulation due to manipulation of the heart and great vessels, the initiation of CPB secondary to a reduction of MAP and acute hemodilution, the use of low flows or circulatory arrest, the rewarming period, weaning from CPB, and the initiation of MUF.</p><p id="par0070" class="elsevierStylePara elsevierViewall">The limits of cerebral autoregulation are better defined in adults. However, for younger children (under 2 years of age) the limits are determined by age and underlying heart disease. Maintaining cerebral autoregulation during CPB contributes to a constant cerebral blood flow preventing neurological complications.<a class="elsevierStyleCrossRef" href="#bib0105"><span class="elsevierStyleSup">10</span></a> NIRS monitoring can help identify situations of imbalanced delivery and consumption of oxygen in the brain, even in the absence of pulsatile activity as during CPB and to correct the underlying cause, by applying action algorithms that have shown to decrease the incidence of neurological damage associated to the intraoperative period.<a class="elsevierStyleCrossRefs" href="#bib0085"><span class="elsevierStyleSup">6,9</span></a></p><p id="par0075" class="elsevierStylePara elsevierViewall">In the case presented here, abnormal asymmetry was observed (over 10%) with further declines in the right hemisphere, exceeding the threshold of cerebral ischemia and tissue hypoxia (over 20% of baseline). The episodes of asymmetry were detected during critical points of the intervention (cannulation and initiation of CPB, rewarming, weaning from CPB and initiation of MUF), as described by other authors.<a class="elsevierStyleCrossRefs" href="#bib0060"><span class="elsevierStyleSup">1,2</span></a> Bilateral NIRS monitoring showed that during periods of imbalanced delivery and consumption of oxygen in the brain (cerebral stress) both hemispheres behaved differently regarding the consumption of oxygen. The right hemisphere (healthy hemisphere) has a higher density of functional active brain tissue with an increased oxygen consumption and, therefore, higher neurological vulnerability in situations of ischemia, whereas the left hemisphere had suffered an embolic stroke 8 months prior leading to initially severe contralateral hemiparesis which was currently mild (<a class="elsevierStyleCrossRef" href="#fig0005">Fig. 1</a>).</p><p id="par0080" class="elsevierStylePara elsevierViewall">Asymmetry is minimal after the cessation of CPB and the restoration of spontaneous pulsatile circulation, supported by the hemoconcentrator effect of MUF (increased hematocrit, increased cerebral perfusion pressure, increased MAP and decreased central venous pressure).</p><p id="par0085" class="elsevierStylePara elsevierViewall">In patients who have suffered strokes and present persistent moderate hemiparesis in the chronic phase (3 months after the episode), patterns of cortical neuronal activation with increased metabolic activity in the contralateral hemisphere have been described, entailing functional motor recovery after injury.<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">3</span></a> In our case, hemiparesis is in functional recovery. The level of activity in the contralateral hemisphere (right hemisphere) may therefore be greater as it assumes the functions of the damaged hemisphere, making it more vulnerable to periods of brain stress at critical points during surgery.</p><p id="par0090" class="elsevierStylePara elsevierViewall">This case shows the importance of bilateral NIRS monitoring, since the previously damaged hemisphere consumed less oxygen and higher registers are obtained. With unilateral NIRS monitoring ischemic critical situations can be thus remain undetected. Multimodal NIRS-BIS monitoring can help identify cerebral hypoperfusion thresholds regarding alterations of brain function and can also support improved neurological outcomes.<a class="elsevierStyleCrossRefs" href="#bib0090"><span class="elsevierStyleSup">7,10</span></a> Although BIS has not been tested in children under 2 years of age, when used in conjunction with NIRS and when used to measure functional brain activity it can form the basis of strategies aimed at reducing oxygen consumption during cerebral hypoperfusion by increasing, if necessary, anesthetic depth or by avoiding overdosing when the anesthetic depth is optimal.<a class="elsevierStyleCrossRef" href="#bib0090"><span class="elsevierStyleSup">7</span></a> In our case, we increased anesthetic depth by administering propofol (as reflected by BIS record) therefore reducing the consumption of oxygen in the brain and stabilizing tissue hypoxia until target hypothermia was reached (<a class="elsevierStyleCrossRef" href="#fig0010">Fig. 2</a>).</p><p id="par0095" class="elsevierStylePara elsevierViewall">We therefore conclude that this case supports the importance of multimodal neuromonitoring (NIRS-BIS) to implement therapeutic strategies that support a balanced relationship between the delivery and consumption of oxygen in the brain. We also consider that bilateral NIRS monitoring is essential because of different behaviors regarding the consumption of oxygen in both hemispheres. Although such differences may not be present at baseline, they can arise in different clinical scenarios during the intraoperative period. In this case, in a patient with a previous stroke, it allowed to detect and treat cerebral ischemia-hypoxia in the healthy hemisphere which could have lead to additional neurological damage.</p></span><span id="sec0020" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0040">Ethical disclosures</span><span id="sec0025" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0045">Protection of human and animal subjects</span><p id="par0100" class="elsevierStylePara elsevierViewall">The authors declare that no experiments were performed on humans or animals for this investigation.</p></span><span id="sec0030" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0050">Confidentiality of data</span><p id="par0105" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span><span id="sec0035" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0055">Right to privacy and informed consent</span><p id="par0110" class="elsevierStylePara elsevierViewall">The authors declare that no patient data appears in this article.</p></span></span><span id="sec0040" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0060">Conflicts of interest</span><p id="par0115" class="elsevierStylePara elsevierViewall">The authors have no conflicts of interest to declare.</p></span></span>" "textoCompletoSecciones" => array:1 [ "secciones" => array:10 [ 0 => array:3 [ "identificador" => "xres1008347" "titulo" => "Abstract" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0005" ] ] ] 1 => array:2 [ "identificador" => "xpalclavsec968020" "titulo" => "Keywords" ] 2 => array:3 [ "identificador" => "xres1008348" "titulo" => "Resumen" "secciones" => array:1 [ 0 => array:1 [ "identificador" => "abst0010" ] ] ] 3 => array:2 [ "identificador" => "xpalclavsec968021" "titulo" => "Palabras clave" ] 4 => array:2 [ "identificador" => "sec0005" "titulo" => "Introduction" ] 5 => array:2 [ "identificador" => "sec0010" "titulo" => "Clinical case" ] 6 => array:2 [ "identificador" => "sec0015" "titulo" => "Discussion" ] 7 => array:3 [ "identificador" => "sec0020" "titulo" => "Ethical disclosures" "secciones" => array:3 [ 0 => array:2 [ "identificador" => "sec0025" "titulo" => "Protection of human and animal subjects" ] 1 => array:2 [ "identificador" => "sec0030" "titulo" => "Confidentiality of data" ] 2 => array:2 [ "identificador" => "sec0035" "titulo" => "Right to privacy and informed consent" ] ] ] 8 => array:2 [ "identificador" => "sec0040" "titulo" => "Conflicts of interest" ] 9 => array:1 [ "titulo" => "References" ] ] ] "pdfFichero" => "main.pdf" "tienePdf" => true "fechaRecibido" => "2016-08-31" "fechaAceptado" => "2017-06-22" "PalabrasClave" => array:2 [ "en" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Keywords" "identificador" => "xpalclavsec968020" "palabras" => array:5 [ 0 => "Near infrared spectroscopy (NIRS)" 1 => "Asymmetry" 2 => "Bispectral index (BIS)" 3 => "Cerebral infarction" 4 => "Multimodal neuromonitoring" ] ] ] "es" => array:1 [ 0 => array:4 [ "clase" => "keyword" "titulo" => "Palabras clave" "identificador" => "xpalclavsec968021" "palabras" => array:5 [ 0 => "Espectroscopia de infrarrojo cercano" 1 => "Asimetría" 2 => "Índice biespectral" 3 => "Infarto cerebral" 4 => "Neuromonitorización multimodal" ] ] ] ] "tieneResumen" => true "resumen" => array:2 [ "en" => array:2 [ "titulo" => "Abstract" "resumen" => "<span id="abst0005" class="elsevierStyleSection elsevierViewall"><p id="spar0005" class="elsevierStyleSimplePara elsevierViewall">Cerebral oximetry based on near infrared spectroscopy (NIRS) technology is used to determine cerebral tissue oxygenation. We hereby present the clinical case of a 12-month old child with right hemiparesis secondary to prior left middle cerebral artery stroke 8 months ago. The child underwent surgical enlargement of the right ventricular outflow tract (RVOT) with cardiopulmonary bypass. During cardiopulmonary bypass, asymmetric NIRS results were detected between both hemispheres. The utilization of multimodal neuromonitoring (NIRS-BIS) allowed acting on both perfusion pressure and anesthetic depth to balance out the supply and demand of cerebral oxygen consumption. No new neurological sequelae were observed postoperatively. We consider bilateral NIRS monitoring necessary in order to detect asymmetries between cerebral hemispheres. Although asymmetries were not present at baseline, they can arise intraoperatively and its monitoring thus allows the detection and treatment of cerebral ischemia-hypoxia in the healthy hemisphere, which if undetected and untreated would lead to additional neurological damage.</p></span>" ] "es" => array:2 [ "titulo" => "Resumen" "resumen" => "<span id="abst0010" class="elsevierStyleSection elsevierViewall"><p id="spar0010" class="elsevierStyleSimplePara elsevierViewall">La oximetría cerebral «near infrared spectroscopy» (NIRS) determina la oxigenación tisular cerebral. Describimos el caso clínico de un niño de 12 meses de edad con hemiparesia derecha secundaria a infarto de arteria cerebral media izquierda hacía 8 meses. El niño fue sometido a una ampliación del tracto de salida del ventrículo derecho por estenosis pulmonar mediante bypass cardiopulmonar. En periodos del bypass cardiopulmonar se detectan asimetrías NIRS entre ambos hemisferios cerebrales con descensos críticos en hemisferio derecho lo que indica estados de perfusión y consumo de oxígeno diferentes entre los 2 hemisferios. La utilización de neuromonitorización multimodal NIRS-BIS permitió actuar sobre la presión de perfusión y profundidad anestésica para equilibrar la balanza entre el aporte y el consumo de oxígeno cerebral. No se detectó daño neurológico sobreañadido en el postoperatorio.</p><p id="spar0015" class="elsevierStyleSimplePara elsevierViewall">Consideramos necesaria la monitorización NIRS bilateral para detectar asimetrías entre los 2 hemisferios, que aunque no se manifiesten en el registro basal, pueden surgir en el periodo intraoperatorio, permitiendo detectar y tratar la isquemia-hipoxia cerebral en el hemisferio sano, que provocaría un daño neurológico sobreañadido.</p></span>" ] ] "NotaPie" => array:1 [ 0 => array:2 [ "etiqueta" => "☆" "nota" => "<p class="elsevierStyleNotepara" id="npar0005">Please cite this article as: Matcan S, Sanabria Carretero P, Gómez Rojo M, Castro Parga L, Reinoso-Barbero F. Importancia de la monitorización bilateral de la oxigenación cerebral: caso clínico de asimetría durante el bypass cardiopulmonar secundaria a infarto cerebral previo. Rev Esp Anestesiol Reanim. 2018;65:165–169.</p>" ] ] "multimedia" => array:2 [ 0 => array:7 [ "identificador" => "fig0005" "etiqueta" => "Figure 1" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr1.jpeg" "Alto" => 587 "Ancho" => 1500 "Tamanyo" => 61770 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0020" class="elsevierStyleSimplePara elsevierViewall">Craneal TAC (left) and craneal RMN (right) showing signals compatible with acute middle cerebral artery stroke.</p>" ] ] 1 => array:7 [ "identificador" => "fig0010" "etiqueta" => "Figure 2" "tipo" => "MULTIMEDIAFIGURA" "mostrarFloat" => true "mostrarDisplay" => false "figura" => array:1 [ 0 => array:4 [ "imagen" => "gr2.jpeg" "Alto" => 2015 "Ancho" => 2904 "Tamanyo" => 347038 ] ] "descripcion" => array:1 [ "en" => "<p id="spar0025" class="elsevierStyleSimplePara elsevierViewall">Multimodal neuromonitoring NIRS-BIS. During CPB the NIRS shows some asymmetry between cerebral hemispheres (high oxygen consumption in the right hemisphere). SrO<span class="elsevierStyleInf">2</span>–Regional cerebral tissue oxygenation; CPB–cardiopulmonary bypass; MUF–modified ultrafiltration.</p>" ] ] ] "bibliografia" => array:2 [ "titulo" => "References" "seccion" => array:1 [ 0 => array:2 [ "identificador" => "bibs0015" "bibliografiaReferencia" => array:11 [ 0 => array:3 [ "identificador" => "bib0060" "etiqueta" => "1" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebral oximetry in cardiac anesthesia" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "G. Vretzakis" 1 => "S. Georgopoulou" 2 => "K. Stamoulis" 3 => "G. Stamatiou" 4 => "K. Tsakiridis" 5 => "P. Zarogoulidis" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.3978/j.issn. 2072-1439.2013.10.22" "Revista" => array:7 [ "tituloSerie" => "J Thorac Dis" "fecha" => "2014" "volumen" => "6" "numero" => "Suppl 1" "paginaInicial" => "S60" "paginaFinal" => "S69" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24672700" "web" => "Medline" ] ] ] ] ] ] ] ] 1 => array:3 [ "identificador" => "bib0065" "etiqueta" => "2" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Casos clínicos. Oximetria cerebral transcutánea" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "P. Sanabria Carretero" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "CERSA Madrid" "fecha" => "2010" "volumen" => "5" "paginaInicial" => "20" "paginaFinal" => "30" ] ] ] ] ] ] 2 => array:3 [ "identificador" => "bib0070" "etiqueta" => "3" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Near-infrared spectroscopy and motor lateralization after stroke: a case series study" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "K. Takeda" 1 => "Y. Gomi" 2 => "H. Kato" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:4 [ "tituloSerie" => "Int J Phys Med Rehabil" "fecha" => "2014" "volumen" => "2" "paginaInicial" => "192" ] ] ] ] ] ] 3 => array:3 [ "identificador" => "bib0075" "etiqueta" => "4" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Near infrared spectroscopy for cerebral monitoring during cardiovascular surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:4 [ 0 => "M. La Monaca" 1 => "A. David" 2 => "R. Gaeta" 3 => "S. Lentini" ] ] ] ] ] "host" => array:1 [ 0 => array:1 [ "Revista" => array:5 [ "tituloSerie" => "Clin Ther" "fecha" => "2010" "volumen" => "161" "paginaInicial" => "549" "paginaFinal" => "553" ] ] ] ] ] ] 4 => array:3 [ "identificador" => "bib0080" "etiqueta" => "5" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Survey of the clinical assessment and utility of near-infrared cerebral oximetry in cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "D. Zacharias" 1 => "K. Lilly" 2 => "C.L. Shaw" 3 => "P. Pirundini" 4 => "R.J. Rizzo" 5 => "S.C. Body" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1053/j.jvca.2013.06.003" "Revista" => array:6 [ "tituloSerie" => "J Cardiothorac Vasc Anesth" "fecha" => "2014" "volumen" => "28" "paginaInicial" => "308" "paginaFinal" => "316" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/24140084" "web" => "Medline" ] ] ] ] ] ] ] ] 5 => array:3 [ "identificador" => "bib0085" "etiqueta" => "6" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebral oximetry: monitoring the brain as the index organ" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:1 [ 0 => "J.M. Murkin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ALN.0b013e3181fef5d2" "Revista" => array:7 [ "tituloSerie" => "Anesthesiology" "fecha" => "2011" "volumen" => "114" "paginaInicial" => "12" "paginaFinal" => "13" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/21178667" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673600045724" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 6 => array:3 [ "identificador" => "bib0090" "etiqueta" => "7" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebral monitoring to optimize outcomes after cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:2 [ 0 => "C. Fedorow" 1 => "H.P. Grocott" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1097/ACO.0b013e3283346d10" "Revista" => array:6 [ "tituloSerie" => "Curr Opin Anaesthesiol" "fecha" => "2010" "volumen" => "23" "paginaInicial" => "89" "paginaFinal" => "94" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19920759" "web" => "Medline" ] ] ] ] ] ] ] ] 7 => array:3 [ "identificador" => "bib0095" "etiqueta" => "8" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebral oxygen desaturation predicts cognitive decline and longer hospital stay after cardiac surgery" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "J.P. Slater" 1 => "T. Guarino" 2 => "J. Stack" 3 => "K. Vinod" 4 => "R.T. Bustami" 5 => "J.M. Brown 3rd" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1016/j.athoracsur.2008.08.070" "Revista" => array:6 [ "tituloSerie" => "Ann Thorac Surg" "fecha" => "2009" "volumen" => "87" "paginaInicial" => "36" "paginaFinal" => "44" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/19101265" "web" => "Medline" ] ] ] ] ] ] ] ] 8 => array:3 [ "identificador" => "bib0100" "etiqueta" => "9" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "A proposed algorithm for the intraoperative use of cerebral near-infrared spectroscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => false "autores" => array:3 [ 0 => "A. Denault" 1 => "A. Deschamps" 2 => "J.M. Murkin" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1177/1089253207311685" "Revista" => array:6 [ "tituloSerie" => "Semin Cardiothorac Vasc Anesth" "fecha" => "2007" "volumen" => "11" "paginaInicial" => "274" "paginaFinal" => "281" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/18270192" "web" => "Medline" ] ] ] ] ] ] ] ] 9 => array:3 [ "identificador" => "bib0105" "etiqueta" => "10" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Abnormal brain development in newborns with congenital heart disease" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "S.P. Miller" 1 => "P.S. McQuillen" 2 => "S. Hamrick" 3 => "D. Xu" 4 => "D.V. Glidden" 5 => "N. Charlton" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1056/NEJMoa067393" "Revista" => array:7 [ "tituloSerie" => "N Engl J Med" "fecha" => "2007" "volumen" => "357" "paginaInicial" => "1928" "paginaFinal" => "1938" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/17989385" "web" => "Medline" ] ] "itemHostRev" => array:3 [ "pii" => "S0140673602095582" "estado" => "S300" "issn" => "01406736" ] ] ] ] ] ] ] 10 => array:3 [ "identificador" => "bib0110" "etiqueta" => "11" "referencia" => array:1 [ 0 => array:2 [ "contribucion" => array:1 [ 0 => array:2 [ "titulo" => "Cerebral ischaemia during cardiac surgery in children detected by combined monitoring of BIS and near-infrared spectroscopy" "autores" => array:1 [ 0 => array:2 [ "etal" => true "autores" => array:6 [ 0 => "M. Hayashida" 1 => "N. Kin" 2 => "T. Tomioka" 3 => "R. Orii" 4 => "H. Sekiyama" 5 => "H. Usui" ] ] ] ] ] "host" => array:1 [ 0 => array:2 [ "doi" => "10.1093/bja/aeh120" "Revista" => array:6 [ "tituloSerie" => "Br J Anaesth" "fecha" => "2004" "volumen" => "92" "paginaInicial" => "662" "paginaFinal" => "669" "link" => array:1 [ 0 => array:2 [ "url" => "https://www.ncbi.nlm.nih.gov/pubmed/15033888" "web" => "Medline" ] ] ] ] ] ] ] ] ] ] ] ] ] "idiomaDefecto" => "en" "url" => "/23411929/0000006500000003/v3_201803240409/S2341192918300118/v3_201803240409/en/main.assets" "Apartado" => null "PDF" => "https://static.elsevier.es/multimedia/23411929/0000006500000003/v3_201803240409/S2341192918300118/v3_201803240409/en/main.pdf?idApp=UINPBA00004N&text.app=https://www.elsevier.es/" "EPUB" => "https://multimedia.elsevier.es/PublicationsMultimediaV1/item/epub/S2341192918300118?idApp=UINPBA00004N" ]
