Article Data

  • Views 4845
  • Dowloads 945


Open Access Special Issue

Cerebral oxygenation monitoring in patients during and after cardiac arrest -- a narrative review of current methods and evidence

  • Jaromir Richter1
  • Jan Maca1
  • Nilay Chatterjee2
  • Peter Sklienka1
  • Adarsh Eshappa Setra2
  • Roman Zahorec3

1Department of Anesthesiology and Intensive Care Medicine, University Hospital Ostrava, 708 00 Ostrava, Czech Republic

2Department of Anaesthetics, Yeovil Hospital, BA21 4AT Yeovil, UK

3Second Department of Anesthesiology and Intensive Medicine, Medical School, Comenius University, 814 99 Bratislava, Slovak Republic

DOI: 10.22514/sv.2021.141 Vol.17,Issue 6,November 2021 pp.18-24

Submitted: 17 June 2021 Accepted: 20 July 2021

Published: 08 November 2021

(This article belongs to the Special Issue Emergency Department Cardiac Arrest (EDCA))

*Corresponding Author(s): Jaromir Richter E-mail:


Hypoxic-ischemic brain injury (HIBI) is a leading cause of mortality in post-cardiac arrest (post-CA) patients who successfully survive the initial cardiopulmonary resuscitation (CPR) but later die in the Intensive Care Unit (ICU). Therefore, a key priority of post-resuscitation ICU care is to prevent and limit the impact of HIBI by optimizing the balance between cerebral oxygen delivery and demand. Traditionally, an optimal systemic oxygen balance is considered to ensure the brain’s oxygen balance. However, the validity of this assumption is uncertain, as the brain constitutes only 2% of the body mass while accounting for approximately 20% of basal oxygen consumption at rest. Hence, there is a real need to monitor cerebral oxygenation realistically. Several imaging and bedside monitoring methods are available for cerebral oxygenation monitoring in post-CA patients. Unfortunately, each of them has its limitations. Imaging methods require transporting a critically ill unstable patient to the scanner. Moreover, they provide an assessment of the oxygenation state only at a particular moment, while brain oxygenation is dynamic. Bedside methods, specifically near-infrared spectroscopy (NIRS), brain tissue oxygen tension (PbtO2), and jugular venous oxygen saturation monitoring (SjvO2), have not often been used in studies involving post-CA patients. Hence there is ambiguity regarding clear recommendations for using these bedside monitors. Presently, the most promising option seems to be using the NIRS as an indicator of effective CPR. We present a narrative review focusing on bedside methods and discuss the evidence for their use in adult patients after cardiac arrest.


Cerebral oxygenation monitoring; Near-infrared spectroscopy; Brain tissue oxygen tension monitoring; Jugular venous oxygen saturation monitoring

Cite and Share

Jaromir Richter,Jan Maca,Nilay Chatterjee,Peter Sklienka,Adarsh Eshappa Setra,Roman Zahorec. Cerebral oxygenation monitoring in patients during and after cardiac arrest -- a narrative review of current methods and evidence. Signa Vitae. 2021. 17(6);18-24.


[1] Nolan JP, Soar J, Smith GB, Gwinnutt C, Parrott F, Power S, et al. Incidence and outcome of in-hospital cardiac arrest in the United Kingdom National Cardiac Arrest Audit. Resuscitation. 2014; 85: 987–992.

[2] Fennessy G, Hilton A, Radford S, Bellomo R, Jones D. The epidemiology of in-hospital cardiac arrests in Australia and New Zealand. Internal Medicine Journal. 2016; 46: 1172–1181.

[3] Gräsner JT, Lefering R, Koster RW, Masterson S, Böttiger BW, Herlitz J, et al. EuReCa ONE-27 Nations, ONE Europe, ONE Registry: A prospective one month analysis of out-of-hospital cardiac arrest outcomes in 27 countries in Europe. Resuscitation. 2016; 105: 188–195.

[4] Yan S, Gan Y, Jiang N, Wang R, Chen Y, Luo Z, et al. The global survival rate among adult out-of-hospital cardiac arrest patients who received cardiopulmonary resuscitation: a systematic review and meta-analysis. Critical Care. 2020; 24: 61.

[5] Binks A, Nolan JP. Post-cardiac arrest syndrome. Minerva Anestesiolog-ica. 2010; 76: 362–368.

[6] Lemiale V, Dumas F, Mongardon N, Giovanetti O, Charpentier J, Chiche J, et al. Intensive care unit mortality after cardiac arrest: the relative contribution of shock and brain injury in a large cohort. Intensive Care Medicine. 2013; 39: 1972–1980.

[7] Nolan JP, Soar J, Cariou A, Cronberg T, Moulaert VRM, Deakin CD, et al. European Resuscitation Council and European Society of Intensive Care Medicine Guidelines for Post-resuscitation Care 2015: Section 5 of the European Resuscitation Council Guidelines for Resuscitation 2015. Resuscitation. 2015; 95: 202–222.

[8] Rodgers ZB, Detre JA, Wehrli FW. MRI-based methods for quantification of the cerebral metabolic rate of oxygen. Journal of Cerebral Blood Flow and Metabolism. 2016; 36: 1165–1185.

[9] Dagal A, Lam AM. Cerebral blood flow and the injured brain: how should we monitor and manipulate it? Current Opinion in Anaesthesiology. 2011; 24: 131–137.

[10] Jöbsis FF. Noninvasive, infrared monitoring of cerebral and myocardial oxygen sufficiency and circulatory parameters. Science. 1977; 198: 1264–1267.

[11] Tosh W, Patteril M. Cerebral oximetry. BJA Education. 2016; 16: 417–421.

[12] Meaney PA, Bobrow BJ, Mancini ME, Christenson J, de Caen AR, Bhanji F, et al. Cardiopulmonary resuscitation quality: [corrected] improving cardiac resuscitation outcomes both inside and outside the hospital: a consensus statement from the American Heart Association. Circulation. 2013; 128: 417–435.

[13] Schnaubelt S, Sulzgruber P, Menger J, Skhirtladze-Dworschak K, Sterz F, Dworschak M. Regional cerebral oxygen saturation during cardiopulmonary resuscitation as a predictor of return of spontaneous circulation and favourable neurological outcome—a review of the current literature. Resuscitation. 2018; 125: 39–47.

[14] Liu Y, Jing K, Liu H, Mu Y, Jiang Z, Nie Y, et al. Association between cerebral oximetry and return of spontaneous circulation following cardiac arrest: A systematic review and meta-analysis. PLoS ONE. 2020; 15: e0234979.

[15] Takegawa R, Hayashida K, Rolston DM, Li T, Miyara SJ, Ohnishi M, et al. Near-Infrared Spectroscopy Assessments of Regional Cerebral Oxygen Saturation for the Prediction of Clinical Outcomes in Patients With Cardiac Arrest: A Review of Clinical Impact, Evolution, and Future Directions. Frontiers in Medicine. 2020; 7: 587930.

[16] Cournoyer A, Iseppon M, Chauny J, Denault A, Cossette S, Notebaert É. Near-infrared Spectroscopy Monitoring during Cardiac Arrest: a Systematic Review and Meta-analysis. Academic Emergency Medicine. 2016; 23: 851–862.

[17] Genbrugge C, De Deyne C, Eertmans W, Anseeuw K, Voet D, Mertens I, et al. Cerebral saturation in cardiac arrest patients measured with near-infrared technology during pre-hospital advanced life support. Results from Copernicus I cohort study. Resuscitation. 2018; 129: 107–113.

[18] Nishizawa H, Kudoh I. Cerebral autoregulation is impaired in patients resuscitated after cardiac arrest. Acta Anaesthesiologica Scandinavica. 1996; 40: 1149–1153.

[19] Sundgreen C, Larsen FS, Herzog TM, Knudsen GM, Boesgaard S, Aldershvile J. Autoregulation of cerebral blood flow in patients resuscitated from cardiac arrest. Stroke. 2001; 32: 128–132.

[20] Ameloot K, Genbrugge C, Meex I, Jans F, Boer W, Vander Laenen M, et al. An observational near-infrared spectroscopy study on cerebral autoregulation in post-cardiac arrest patients: time to drop ’one-size-fits-all’ hemodynamic targets? Resuscitation. 2015; 90: 121–126.

[21] Griesdale DEG, Rikhraj KJK, Wood MD, Hoiland RL, Thiara S, Sekhon MS. Determining Optimal Mean Arterial Pressure after Cardiac Arrest: a Systematic Review. Neurocritical Care. 2021; 34: 621–634.

[22] Storm C, Leithner C, Krannich A, Wutzler A, Ploner CJ, Trenkmann L, et al. Regional cerebral oxygen saturation after cardiac arrest in 60 patients–a prospective outcome study. Resuscitation. 2014; 85: 1037–1041.

[23] Ahn A, Yang J, Inigo-Santiago L, Parnia S. A feasibility study of cerebral oximetry monitoring during the post-resuscitation period in comatose patients following cardiac arrest. Resuscitation. 2014; 85: 522–526.

[24] Jakkula P, Hästbacka J, Reinikainen M, Pettilä V, Loisa P, Tiainen M, et al. Near-infrared spectroscopy after out-of-hospital cardiac arrest. Critical Care. 2019; 23: 171.

[25] Kyttä J, Ohman J, Tanskanen P, Randell T. Extracranial contribution to cerebral oximetry in brain dead patients: a report of six cases. Journal of Neurosurgical Anesthesiology. 1999; 11: 252–254.

[26] Billet N, Meex I, Vanderlaenen M, Heylen R, Boer W, De Deyne C, et al. Cerebral oximetry and brain death in the ICU: data from seven cases. Critical Care. 2012; 16: P294.

[27] Caccioppola A, Carbonara M, Macrì M, Longhi L, Magnoni S, Ortolano F, et al. Ultrasound-tagged near-infrared spectroscopy does not disclose absent cerebral circulation in brain-dead adults. British Journal of Anaesthesia. 2018; 121: 588–594.

[28] Cardim D, Griesdale DE. Near-infrared spectroscopy: unfulfilled promises. British Journal of Anaesthesia. 2018; 121: 523–526.

[29] Sandroni C, Parnia S, Nolan JP. Cerebral oximetry in cardiac arrest: a potential role but with limitations. Intensive Care Medicine. 2019; 45: 904–906.

[30] Dunn J, Mythen M, Grocott M. Physiology of oxygen transport. BJA Education. 2016; 16: 341–348.

[31] Lang EW, Mulvey JM, Mudaliar Y, Dorsch NWC. Direct cerebral oxygenation monitoring–a systematic review of recent publications. Neurosurgical Review. 2007; 30: 99–97.

[32] Clark LC Jr, Lyons C. Electrode systems for continuous monitoring in cardiovascular surgery. Annals of the New York Academy of Sciences. 1962; 102: 29–45

[33] Maas AI, Fleckenstein W, de Jong DA, van Santbrink H. Monitoring cerebral oxygenation: experimental studies and preliminary clinical results of continuous monitoring of cerebrospinal fluid and brain tissue oxygen tension. Acta Neurochirurgica. Supplementum. 1993; 59: 50–57.

[34] Huschak G, Hoell T, Hohaus C, Kern C, Minkus Y, Meisel H. Clinical evaluation of a new multiparameter neuromonitoring device: measurement of brain tissue oxygen, brain temperature, and intracranial pressure. Journal of Neurosurgical Anesthesiology. 2009; 21: 155–160.

[35] Haitsma I, Rosenthal G, Morabito D, Rollins M, Maas AIR, Manley GT. In vitro comparison of two generations of Licox and Neurotrend catheters. Acta Neurochirurgica Supplements. 2008; 71: 197–202.

[36] Jaeger M, Soehle M, Meixensberger J. Brain tissue oxygen (PtiO2): a clinical comparison of two monitoring devices. Acta Neurochirurgica. Supplement. 2005; 95: 79–81.

[37] Purins K, Enblad P, Sandhagen B, Lewén A. Brain tissue oxygen monitoring: a study of in vitro accuracy and stability of Neurovent-PTO and Licox sensors. Acta Neurochirurgica. 2010; 152: 681–688.

[38] Morgalla MH, Haas R, Grözinger G, Thiel C, Thiel K, Schuhmann MU, et al. Experimental comparison of the measurement accuracy of the Licox and Raumedic Neurovent-PTO brain tissue oxygen monitors. Acta Neurochirurgica. Supplement. 2012; 114: 169–172.

[39] van den Brink WA, Haitsma IK, Avezaat CJ, Houtsmuller AB, Kros JM, Maas AI. Brain parenchyma/pO2 catheter interface: a histopathological study in the rat. Journal of Neurotrauma. 1998; 15: 813–824.

[40] van den Brink WA, van Santbrink H, Steyerberg EW, Avezaat CJJ, Suazo JAC, Hogesteeger C, et al. Brain Oxygen Tension in Severe Head Injury. Neurosurgery. 2000; 46: 868–878.

[41] Okonkwo DO, Shutter LA, Moore C, Temkin NR, Puccio AM, Madden

CJ, et al. Brain Oxygen Optimization in Severe Traumatic Brain Injury Phase-II: a Phase II Randomized Trial. Critical Care Medicine. 2017; 45: 1907–1914.

[42] Brain Oxygen Optimization in Severe TBI, Phase 3 - Full Text View Identifier: NCT03754114

[43] Sekhon MS, Gooderham P, Menon DK, Brasher PMA, Foster D, Cardim D, et al. The Burden of Brain Hypoxia and Optimal Mean Arterial Pressure in Patients with Hypoxic Ischemic Brain Injury after Cardiac Arrest. Critical Care Medicine. 2019; 47: 960–969.

[44] Sekhon MS, Ainslie PN, Menon DK, Thiara SS, Cardim D, Gupta AK, et al. Brain Hypoxia Secondary to Diffusion Limitation in Hypoxic Ischemic Brain Injury Postcardiac Arrest. Critical Care Medicine. 2020; 48: 378–384.

[45] Schell RM, Cole DJ. Cerebral monitoring: jugular venous oximetry. Anesthesia and Analgesia. 2000; 90: 559–566.

[46] Sharma D, Lele A. Monitoring of Jugular Venous Oxygen Saturation. In: Koht A, Sloan T, Toleikis J (ed.) Monitoring the Nervous System for Anesthesiologists and Other health Care Professionals. Cham: Springer. 2017.

[47] Cormio M, Robertson CS. Ultrasound is a reliable method for determining jugular bulb dominance. Journal of Neurosurgical Anesthesiology. 2001; 13: 250–254.

[48] Carney N, Totten AM, O’Reilly C, Ullman JS, Hawryluk GW, Bell MJ, et al. Guidelines for the Management of Severe Traumatic Brain Injury, Fourth Edition. Neurosurgery. 2017; 80: 6–15.

[49] Takasu A, Yagi K, Ishihara S, Okada Y. Combined continuous monitoring of systemic and cerebral oxygen metabolism after cardiac arrest. Resuscitation. 1995; 29: 189–194.

[50] Zarzuelo R, Castañeda J. Differences in oxygen content between mixed venous blood and cerebral venous blood for outcome prediction after cardiac arrest. Intensive Care Medicine. 1995; 21: 71–75.

[51] van der Hoeven JG, de Koning J, Compier EA, Meinders AE. Early jugular bulb oxygenation monitoring in comatose patients after an out-of-hospital cardiac arrest. Intensive Care Medicine. 1995; 21: 567–572.

[52] Richter J, Sklienka P, Setra AE, Zahorec R, Das S, Chatterjee N. Is jugular bulb oximetry monitoring associated with outcome in out of hospital cardiac arrest patients? Journal of Clinical Monitoring and Computing. 2021; 35: 741–748.

[53] Buunk G, van der Hoeven JG, Meinders AE. Prognostic significance of the difference between mixed venous and jugular bulb oxygen saturation in comatose patients resuscitated from a cardiac arrest. Resuscitation. 1999; 41: 257–262.

[54] Lemiale V, Huet O, Vigué B, Mathonnet A, Spaulding C, Mira J, et al. Changes in cerebral blood flow and oxygen extraction during post-resuscitation syndrome. Resuscitation. 2008; 76: 17–24.

[55] Hoedemaekers CW, Ainslie PN, Hinssen S, Aries MJ, Bisschops LL, Hofmeijer J, et al. Low cerebral blood flow after cardiac arrest is not associated with anaerobic cerebral metabolism. Resuscitation. 2017; 120: 45–50.

[56] Verweij BH, Muizelaar JP, Vinas FC, Peterson PL, Xiong Y, Lee CP. Impaired cerebral mitochondrial function after traumatic brain injury in humans. Journal of Neurosurgery. 2000; 93: 815–820.

[57] Menon DK, Coles JP, Gupta AK, Fryer TD, Smielewski P, Chatfield DA, et al. Diffusion limited oxygen delivery following head injury. Critical Care Medicine. 2004; 32: 1384–1390.

[58] Sekhon MS, Ainslie PN, Menon DK, Thiara SS, Cardim D, Gupta AK, et al. Brain Hypoxia Secondary to Diffusion Limitation in Hypoxic Ischemic Brain Injury Postcardiac Arrest. Critical Care Medicine. 2020; 48: 378–384.

[59] Nolan JP, Sandroni C, Böttiger BW, Cariou A, Cronberg T, Friberg H, et al. European Resuscitation Council and European Society of Intensive Care Medicine guidelines 2021: post-resuscitation care. Intensive Care Medicine. 2021; 47: 369–421.

Abstracted / indexed in

Science Citation Index Expanded (SciSearch) Created as SCI in 1964, Science Citation Index Expanded now indexes over 9,200 of the world’s most impactful journals across 178 scientific disciplines. More than 53 million records and 1.18 billion cited references date back from 1900 to present.

Journal Citation Reports/Science Edition Journal Citation Reports/Science Edition aims to evaluate a journal’s value from multiple perspectives including the journal impact factor, descriptive data about a journal’s open access content as well as contributing authors, and provide readers a transparent and publisher-neutral data & statistics information about the journal.

Chemical Abstracts Service Source Index The CAS Source Index (CASSI) Search Tool is an online resource that can quickly identify or confirm journal titles and abbreviations for publications indexed by CAS since 1907, including serial and non-serial scientific and technical publications.

Index Copernicus The Index Copernicus International (ICI) Journals database’s is an international indexation database of scientific journals. It covered international scientific journals which divided into general information, contents of individual issues, detailed bibliography (references) sections for every publication, as well as full texts of publications in the form of attached files (optional). For now, there are more than 58,000 scientific journals registered at ICI.

Geneva Foundation for Medical Education and Research The Geneva Foundation for Medical Education and Research (GFMER) is a non-profit organization established in 2002 and it works in close collaboration with the World Health Organization (WHO). The overall objectives of the Foundation are to promote and develop health education and research programs.

Scopus: CiteScore 1.0 (2022) Scopus is Elsevier's abstract and citation database launched in 2004. Scopus covers nearly 36,377 titles (22,794 active titles and 13,583 Inactive titles) from approximately 11,678 publishers, of which 34,346 are peer-reviewed journals in top-level subject fields: life sciences, social sciences, physical sciences and health sciences.

Embase Embase (often styled EMBASE for Excerpta Medica dataBASE), produced by Elsevier, is a biomedical and pharmacological database of published literature designed to support information managers and pharmacovigilance in complying with the regulatory requirements of a licensed drug.

Submission Turnaround Time