Near-infrared spectroscopy (NIRS) measurements of cytochrome-c-oxidase (CCO) have the potential to yield crucial information about cerebral metabolism at the patient bedside. Developments in instrumentation and the analytical methods used to resolve changes in CCO have led to many clinical applications of the measurement since its first demonstration in 1977 by Jöbsis. There is a substantial literature of work on measures of CCO in animal and in vitro studies; however, this review focuses on translational studies. Almost 40 years from the advent of the first measurement of CCO using NIRS, this signal continues to hold significant interest in our understanding of the human brain in health and disease. We discuss methodologies for obtaining NIRS measurements of CCO in the clinic and review studies in neonates and adults.

We present a novel lens-based broadband near-infrared spectroscopy system to simultaneously measure cerebral changes in tissue oxygenation and haemodynamics via estimation of the changes in haemoglobin concentration; in addition to oxygen utilization via the measurement of the oxidation state of cytochrome-c-oxidase (CCO). We demonstrate the use of the system in a cohort of 6 newborn infants with neonatal encephalopathy in the Neonatal Intensive Care Unit for continuous measurement periods of up to 5 days. NIRS data was collected from above the frontal lobe on the left and right hemispheres simultaneously with systemic data to allow multimodal data analysis. This allowed us to study the NIRS variables in response to global pathophysiological events and we focused our analysis to spontaneous oxygen desaturations. We identified changes from the NIRS variables during 236 oxygen desaturations from over 212 hours of data with a change from the baseline to nadir of −12 ± 3%. There was a consistent negative change in the Δ[HbD] (= oxygenated – deoxygenated haemoglobin) and Δ[oxCCO] measurements, mean decreases were 3.0 ± 1.7μM and 0.22 ± 0.11μM, and a positive change in the Δ[HbT] (= oxygenated + deoxygenated haemoglobin) measurements across all subjects, mean increase was 0.85 ± 0.58μM. We have shown with a feasibility study that the relationship between haemoglobin oxygenation changes and CCO oxidation changes during these desaturation events was significantly associated with a magnetic resonance spectroscopy (MRS)-measured biomarker of injury severity (r = 0.91, p<0.01).

Optical-imaging biomarkers are defined characteristics measured with an optical imaging modality to indicate normal biological or pathological processes. Optical-imaging biomarkers can help researchers better understand disease development and give clinicians the ability to diagnose and treat diseases in patients.^1,2

There is a need for a method of real-time assessment of brain metabolism during neonatal hypoxic-ischaemic encephalopathy (HIE). We have used broadband near-infrared spectroscopy (NIRS) to monitor cerebral oxygenation and metabolic changes in 50 neonates with HIE undergoing therapeutic hypothermia treatment. In 24 neonates, 54 episodes of spontaneous decreases in peripheral oxygen saturation (desaturations) were recorded between 6 and 81 h after birth. We observed differences in the cerebral metabolic responses to these episodes that were related to the predicted outcome of the injury, as determined by subsequent magnetic resonance spectroscopy derived lactate/N-acetyl-aspartate. We demonstrated that a strong relationship between cerebral metabolism (broadband NIRS-measured cytochrome-c-oxidase (CCO)) and cerebral oxygenation was associated with unfavourable outcome; this is likely to be due to a lower cerebral metabolic rate and mitochondrial dysfunction in severe encephalopathy. Specifically, a decrease in the brain tissue oxidation state of CCO greater than 0.06 µM per 1 µM brain haemoglobin oxygenation drop was able to predict the outcome with 64% sensitivity and 79% specificity (receiver operating characteristic area under the curve = 0.73). With further work on the implementation of this methodology, broadband NIRS has the potential to provide an early, cotside, non-invasive, clinically relevant metabolic marker of perinatal hypoxic-ischaemic injury.

Preterm infants born with very low birth weights are at a high risk of brain injury, in part because the premature brain is believed to be prone to periods of low cerebral blood flow (CBF). Tissue damage is likely to occur if reduction in CBF is sufficient to impair cerebral energy metabolism for extended periods. Therefore, a neuromonitoring method that can detect reductions in CBF, large enough to affect metabolism, could alert the neonatal intensive care team before injury occurs. In this report, we present the development of an optical system that combines diffuse correlation spectroscopy (DCS) for monitoring CBF and broadband near-infrared spectroscopy (B-NIRS) for monitoring the oxidation state of cytochrome c oxidase (oxCCO) – a key biomarker of oxidative metabolism. The hybrid instrument includes a multiplexing system to enable concomitant DCS and B-NIRS measurements while avoiding crosstalk between the two subsystems. The ability of the instrument to monitor dynamic changes in CBF and oxCCO was demonstrated in a piglet model of neonatal hypoxia-ischemia (HI). Experiments conducted in eight animals, including two controls, showed that oxCCO exhibited a delayed response to ischemia while CBF and tissue oxygenation (S_tO₂) responses were instantaneous. These findings suggest that simultaneous neuromonitoring of perfusion and metabolism could provide critical information regarding clinically significant hemodynamic events prior to the onset of brain injury.

It has been 20 years since functional near-infrared spectroscopy (fNIRS) was first used to investigate the evoked haemodynamic response to a stimulus in newborns. The haemodynamic response to functional activation is well-established in adults, with an observed increase in concentration change of oxygenated haemoglobin (∆[HbO2]) and decrease in deoxygenated haemoglobin (∆[HHb]). However, functional studies in newborns have revealed a mixed response, particularly with ∆[HHb] where an inconsistent change in direction is observed. The reason for this heterogeneity is unknown, with potential explanations arising from differing physiology in the developing brain, or differences in instrumentation or methodology. The aim of this review is to collate the findings from studies that have employed fNIRS to monitor cerebral haemodynamics in term newborn infants aged 1 day to 1 month. A total of 46 eligible studies were identified; some studies investigated more than one stimulus type, resulting in a total of 51 reported results. The NIRS parameters reported varied across studies with 50/51 cases reporting ∆[HbO2], 39/51 reporting ∆[HHb] and 13/51 reporting total haemoglobin concentration ∆[HbT] (∆[HbO2] + ∆[HHb]). However, of the 39 cases reporting ∆[HHb] in graphs or tables, only 24 studies explicitly discuss the response (i.e. direction of change) of this variable. In the studies where the fNIRS responses are discussed, 46/51 cases observed an increase in ∆[HbO2], 7/51 observed an increase or varied ∆[HHb] and 2/51 reported a varied or negative ∆[HbT]. An increase in ∆[HbO2] and decrease or no change in ∆[HHb] was observed in 15 studies. By reviewing this body of literature, we have identified that the majority of research articles report an increase in ∆[HbO2] across various functional tasks and did not report the response of ∆[HHb]. Confirming the normal, healthy haemodynamic response in newborns will allow identification of unhealthy patterns and their association to normal neurodevelopment.