GENERAL TOPICS Tutorial 538

Cerebral Oximetry—An Introduction

Dr Adam Carpenter1†
1
Consultant Anaesthetist, Groote Schuur Hospital (University of Cape Town), Cape
Town, South Africa

Edited by: Dr Clara Poon, Consultant Anaesthetist, Queen Mary Hospital, University
of Hong Kong, Hong Kong
†
Corresponding author email: adammsizi@[Link]

Published 31 December 2024 DOI: 10.28923/atotw.538

KEY POINTS
• Cerebral oximetry uses near infrared spectrometry to assess cerebral oxygenation.
• The value derived is a mixed average of the arterial and venous components, and reflects the extraction of oxygen
by the brain.
• It is a trend monitor allowing us to see the ongoing changes in cerebral oxygenation.
• Several brands are available, and clinicians should be aware of the limitations and pitfalls when interpreting their readings.
• It can be used in a wide variety of operations where there is concern about inadequate cerebral perfusion.

INTRODUCTION
“It is a trend monitor of greatest value in situations in which intracranial Hb saturation could dangerously change and in which
changes in systemic haemodynamics and oxygenation would not predict that change.” — Valerie Pollard and Donald S. Prough1
In patients under deep sedation or general anaesthesia, monitoring brain perfusion is crucial for the early detection of cerebral
ischemia. Systemic blood pressure is a poor indicator of cerebral blood flow as it fails to account for interindividual anatomical
variations (e.g., circle of Willis integrity) and physiological differences (e.g., robustness of pressure autoregulation). Alternative methods
for measuring cerebral blood flow, such as transcranial Doppler and radiological perfusion studies, are often operator-dependent
and resource-intensive. Cerebral oximetry, which utilizes near-infrared spectroscopy (NIRS) to assess tissue oxygenation, offers a
noninvasive, objective, and bedside approach to directly evaluate cerebral oxygenation.
In this tutorial, we will introduce this technology, discuss common and recent trends in its clinical utilization, and acknowledge
some of its limitations. Although NIRS has been used in other parts of the body, the use of somatic oximetry will not be covered in
this article.

CEREBRAL OXIMETRY—THE PRINCIPLE

Coined in 1942 by physiologist Glen Milliken, the term “oximetry” refers to the measurement of haemoglobin oxygen saturation
in blood or tissue. Cerebral oximetry is a non-invasive, bedside method for measuring tissue (cerebral) haemoglobin oxygen satu-
ration (ScO2). The basic components of oximetry include a light source that emits light at specific frequencies through a tissue
area, where it is partially absorbed, and light sensors that measure the scattered and unabsorbed light. Light in the near-infrared
spectrum penetrates biological tissues, including the skull and brain, and exhibits distinct absorption patterns in chromophores
such as oxyhaemoglobin, deoxyhaemoglobin, and cytochrome c oxidase. By emitting light in this range and measuring the dif-
ferential absorption, one can determine the relative concentrations of oxyhaemoglobin and deoxyhaemoglobin, thereby

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ATOTW 538 — Cerebral Oximetry—An Introduction (31 December 2024) Page 1 of 7
inferring tissue oxygen saturation and blood flow. If light attenuation between a source and detector is solely due to absorption
by chromophores, it follows the Beer-Lambert law. However, tissue light scattering complicates this measurement and presents
significant technical challenges, which will be explored later. Wavelengths typically used range from 700 to 870 nm, where the
absorption spectra of haemoglobin (Hb) and oxyhemoglobin are maximally separated and overlap with H2O is minimal. The probe,
which contains the light emitter and sensors, is usually placed on the forehead to minimize the effects of hair on light transmission.

Commercial Cerebral Oximeters

There are several commercial cerebral (tissue) oximetry monitors available, all of which operate based on the same basic principles
but utilize slightly different means to address technical obstacles such as light scattering to improve their accuracies (Table 1).
The most common modification in commercial devices is multidistance (or spatially resolved) spectroscopy. This technique is
based on the principle that the depth of tissue investigated is directly proportional to the distance between the light emitter and
light detector. Increasing this distance can enhance the depth of tissue sampled, allowing for the measurement of oxygenation
in the intracranial compartment. Other commercial modifications, such as frequency-resolved spectroscopy and time-resolved
spectroscopy, are rarely used.2
Spatially resolved spectroscopy is employed in several widely used monitors (e.g., SenSmart, FORE-SIGHT, INVOS series, Masimo
O3, NIRO series)2,3 (see Figure 1). Various methods, some of which are proprietary, are utilized to enhance sensitivity. These
include increasing the number of light wavelengths to improve the signal-to-noise ratio, using longer wavelengths to increase
tissue permeation and reduce extracranial interference, and separating the source and detector by a greater distance to allow for
deeper tissue penetration. Different subtraction algorithms are also employed. Consequently, direct comparison of data between
commercial devices is challenging.
A cerebral oximeter measures an unknown mixture of gas-exchanging vessels (arterioles, capillaries, and venules) within the tissue
beneath the sensor. Unlike pulse oximetry, which measures arterial blood oxygenation, cerebral oximetry assesses the entire returned
signal, so pulsatility of tissue components is not required. It evaluates all haemoglobin in the reflectance arc (including those within the
arterial, venous, and capillary compartments), resulting in a value for ScO2 that is biased toward the larger venous haemoglobin
mass, or “venous-weighted.” Manufacturers typically assume a fixed arterial-to-venous ratio, ranging from 25% to 30% for arterial
and 70% to 75% for venous cortical blood volume in their algorithms. However, the actual ratio can vary depending on the individual,
location of the measurement, and dynamic status of the cerebral vasculature.
In healthy adults, the normal cerebral oxygen extraction ratio ranges from 20% to 40%, with a commonly cited “normal value” of
ScO2 between 60% and 80%. Due to significant variation in baseline values, cerebral oximetry is best used as a trend monitor. The
oximetry probe should ideally be placed on the patient before the induction of anaesthesia to establish a patient-specific baseline
ScO2, against which subsequent ScO2 can be compared. There is no consensus on what decrement in cerebral oxygen saturation
from baseline signifies irreversible injury. Nonetheless, a widely used criterion for defining “desaturation” is a reduction of >20%
from baseline or an absolute value of <50%.4
ScO2 is influenced by cerebral blood volume and its oxygenation, which are affected by systemic factors such as blood pressure,
haemoglobin concentration, and arterial oxygen and carbon dioxide partial pressures. Since ScO2 includes arterial and venous
components, it can be considered an indicator of the cerebral oxygen supply-demand balance. Low ScO2 values may indicate
inadequate oxygen delivery (e.g., cerebral hypoperfusion) or increased tissue oxygen extraction due to high metabolic demand
(e.g., seizures). Conversely, high ScO2 values may suggest cerebral hyperperfusion or metabolic suppression. Given the complex
interplay of contributing factors, ScO2 should be interpreted alongside other available data within the appropriate clinical context
(see Table 2).

SenSmart / REGIONAL
Product Name INVOS FORE-SIGHT EQUANOX OXIMETRY
Latest model INVOS 7100 ELITE SenSmart X-100 O3
Manufacturer Covidien CAS Medical System Nonin Masimo
(Medtronic) (Edwards Lifesciences)
Number of 2 (730/810 nm) 5 (685/730/770/810/870 nm) 4 (730/760/810/ 4 (730/760/805/
wavelengths 880 nm) 880 nm)
Notes Adult, paediatric, Utilizing lights from 5 wavelengths Dual emitter design Adult, paediatric,
neonatal sensors lessens interference from offering more light and neonatal
available. melanin and bilirubin. paths for tissue sensors available.
Large, medium, and small sensors interrogations.
available for adults, paediatrics, Adult and paediatric
and neonatal patients. sensors available.
Table 1. Examples of Commercially Available Cerebral Oximeters

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 Figure 1. Diagram of cerebral oximetry with deep and shallow light detector paired with light source
(Courtesy of Ó2023 Masimo Corporation, used with permission).

Several pitfalls and limitations must be considered when interpreting NIRS readings:

1. Extracranial contamination: The NIRS signal can be affected by extracerebral tissues such as the scalp, skull, and
sinuses, leading to inaccurate readings. Significant extracranial contamination has been reported with several commer-
cially available NIRS devices.5,6
2. Spatial resolution and penetration depth: NIRS provides only a regional measure of oxygen saturation, limited to the
superficial layers of the frontal cortex. It does not assess deeper brain structures or global brain tissue.
3. Calibration and baseline variation: There is no universally accepted gold standard for calibrating NIRS devices.
Variability in individuals’ baseline values and differences in device designs make it difficult to establish universal threshold values
for intervention.
4. Lack of universally accepted thresholds: Variability in individuals’ baseline values and differences in device designs
make it difficult to establish universal threshold values for intervention. There is no consensus on what constitutes a significant
desaturation in terms of the duration and magnitude of absolute or relative ScO2 decrement.
5. Signal interpretation and lack of direct CBF measurement: NIRS does not measure cerebral blood flow (CBF) directly. It
provides an indirect assessment of cerebral oxygenation, which can be influenced by CBF, as well as systemic factors such as
changes in arterial carbon dioxide levels, blood pressure, haemoglobin concentration, and cerebral vascular tone. The
degree of venous weighting in the NIRS signal is not constant in real life, and assuming so can complicate the interpretation
of ScO2 data. An example would be the observation that ScO2 often paradoxically decreases after phenylephrine boluses
aimed to increase the arterial blood pressure. This phenomenon has previously caused some confusion but is now believed
to be due to phenylephrine-induced reduction in extracranial blood flow and a decrease in the intracranial arterial-to-venous
blood volume ratio, rather than genuine cerebral ischemia.7
6. Pathological conditions: Certain pathological conditions, such as the presence of hematoma or pneumocephaly in the
measured area, may compromise the accuracy of NIRS measurements.

Factors Leading to Drop

in ScO2 Possible Interventions to Increase ScO2
Cerebral hypoperfusion Increase brain oxygen delivery
• Check head position
• Check central, aortic and/or superior vena cava catheter position
• Improve arterial oxygen saturation (e.g. increase FiO2)
• Aim to increase mean arterial pressure, improve cardiac output using
combination of intravenous fluid administration and inotropes
• Increase extracorporeal circulation pump flow rate
• Optimize haemoglobin
• Avoid hypocarbia
Increase O2 metabolic demand Decrease brain oxygen consumption
• Target temperature management – avoid hyperthermia
• Exclude and treat any seizure
• Increase depth of sedation/anaesthesia

Table 2. Possible Factors Contributing to Low ScO2 and Interventions to Increase ScO2. FiO2 indicates
Fraction of Inspired Oxygen; ScO2, Cerebral Tissue Oxygen Saturation.

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 7. Artifacts: Other chromophores, such as bilirubin and melanin, can interfere with the measurement of tissue oxygenation.
Therefore, establishing a baseline value for each patient individually is crucial. Intravascular dyes, such as indocyanine
green (with a characteristic absorption peak around 805 nm) and methylene blue (with a peak around 668 nm), may also
affect readings.

CLINICAL USE OF CEREBRAL OXIMETRY

The major advantages of cerebral oximetry are its noninvasive nature, ease of setup, and ability to provide real-time feedback
and early warnings of cerebral hypoperfusion, particularly for patients undergoing high-risk surgeries (see Table 3). Below is a brief
overview of its common clinical uses. However, it is important to note that evidence supporting its routine use is not robust. Numerous
studies and meta-analyses have failed to reach definitive conclusions due to the scarcity of large studies, heterogeneity among
studies, high risk of bias, poor adherence to preset protocols, and difficulties in translating data into final clinical outcomes.8 Until more
clinical evidence becomes available, current recommendations are at level III, which suggests that intraoperative ScO2 monitoring
and associated management may reduce postoperative complications.

Carotid Endarterectomy
The initial application of cerebral oximetry, in conjunction with awake neurological monitoring during carotid endarterectomy,
has provided valuable insights into its utility. By comparing drops in ScO2 with neurological assessments in awake patients, it has
been suggested that a 20% drop from baseline ScO2 after carotid cross-clamping is associated with symptomatic cerebral
hypoperfusion, prompting the insertion of a shunt. This 20% threshold, observed under local anaesthesia, resulted in pooled sensitivity
and specificity estimates of 70.5% and 92.4%, respectively, compared with awake neurological monitoring.9 A reduction in cerebral
oximetry values greater than 12% from the baseline preoperative value has been identified as a reliable, sensitive, and specific
indicator of brain ischemia.4 After internal carotid artery cross-clamping, a drop in cerebral oximetry values may suggest the
need for shunt placement during the procedure. Cerebral oximetry provides similar accuracy in detecting ischemia compared
to transcranial Doppler and somatosensory evoked potentials monitoring.10 However, higher-quality evidence using accurate
reference standards and with low risk of bias is needed to determine the diagnostic accuracy of NIRS. It is also controversial whether
intraoperative monitoring improves outcomes in carotid endarterectomies.10

Cardiac Surgery
Cerebral oximetry is utilized in adult and paediatric cardiac surgery, particularly in procedures involving cardiopulmonary bypass.
Intraoperative and postoperative cerebral desaturation occur in up to 64% of patients undergoing cardiac surgery.11,12 Proposed
applications of cerebral oximetry in this context include preoperative risk stratification,13 detecting malposition of aortic and venous
cannula, confirming selective antegrade cerebral perfusion,14 and early detection of hypocapnoea-induced cerebral vasoconstriction
during cardiac bypass, and in close monitoring and treatment of cerebral desaturation in patients with vulnerable brains.
Importantly, Denault et al. introduced an algorithmic, goal-directed approach for treating cerebral desaturation, which includes a
step-by-step process to improve physiological variables affecting cerebral perfusion (see Figure 2).15 The “Denault algorithm” has
been generally effective in reversing most desaturation events,11,12 though not all studies have demonstrated improved
clinical outcomes. Recent meta-analyses have also failed to provide strong evidence for improved postoperative outcomes.16

Paediatric and Neonatal Anaesthesia

Anaesthetists traditionally rely on basic monitoring parameters, such as blood pressure, heart rate, and oxygen saturation, to assess
a patient’s cardiopulmonary status. However, in neonatal and paediatric patients, normal physiological parameters vary significantly
across different age groups. For instance, what is considered a normal blood pressure and heart rate range differ between a
1-month-old neonate and a 3-year-old child. Cerebral oximetry enables clinicians to continuously monitor cardiac output, cerebral
perfusion, and the cerebral oxygen supply-demand balance.17 Any decrease in ScO2 from baseline should prompt an investigation
and aggressive optimization of physiological variables to restore baseline levels.

Patient Factor Carotid Stenosis Unstable Haemodynamic

Surgical Factor Beach chair or sitting surgical position
Permissive hypotension desired
Surgical procedures involving aortic arch, carotid or intracranial vessels
Cardiac bypass or aortic arch surgery
Extracorporeal membrane oxygenation (ECMO) support
Table 3. Examples of Situations When Cerebral Ischemia is Particularly at Risk,
When Monitoring Cerebral Oxygenation May Be Particularly Desirable

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 Figure 2. Algorithm proposed by Denault et al. to reverse intraoperative drop in ScO2.15

Hypotensive Surgery
Cerebral hypoperfusion during surgeries performed in the beach chair position is a well-documented complication. Monitoring blood
pressure at the brachial artery may overestimate perfusion pressure at the level of the brain. Consequently, cerebral oximetry is
becoming increasingly popular for assessing cerebral perfusion adequacy and guiding intraoperative interventions during surgeries
in the beach chair position (e.g., for shoulder surgeries). Several studies have shown that significant decreases in ScO2
occur frequently, with reported incidences of up to 57% under general anaesthesia.18 Despite the high incidence of cerebral desaturation
events, the reported incidence of cerebrovascular events and neurocognitive complications after surgery in the beach chair position
has been low. This unresolved association between intraoperative desaturation events and postoperative cognitive decline has
led some to argue against the routine use of ScO2 in this context. However, with more sensitive neuropsychological testing and
increased awareness, recent literature suggests a higher incidence of postoperative neurocognitive dysfunction, warranting closer
evaluation to address this controversy.19

Other Uses of Cerebral Oximetry

The use of cerebral oximetry has been described in peripheral veno-arterial extracorporeal membrane oxygenation (VA ECMO). In
this setup, blood oxygenated by the extracorporeal oxygenator is delivered into the femoral artery and then up the aorta to perfuse
the upper body and brain. As the heart recovers and cardiac output increases, a watershed point occurs between the deoxygenated
blood expelled from the heart and the oxygenated blood from the extracorporeal circuit. Depending on the location of this point, a
differential perfusion phenomenon, known as “harlequin syndrome,” may occur (see Figure 3).20 Cerebral oximetry can monitor
cerebral perfusion to provide early warnings of inadequate cerebral perfusion or harlequin syndrome.21 Additionally, when applied
to the lower limb as a somatic oximeter, NIRS can be used to monitor lower limb ischemia.

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ATOTW 538 — Cerebral Oximetry—An Introduction (31 December 2024) Page 5 of 7
 Figure 3. Harlequin’s syndrome. Harlequin’s syndrome can arise when relatively de-oxygenated blood, ejected by the left
ventricle in case of poor pulmonary oxygenation, perfuses the aortic arch (Source: Meuwese et al.20).

Cerebral oximetry has also been advocated during cardiopulmonary resuscitation (CPR). The technology’s ability to assess
non-pulsatile flow is particularly beneficial. ScO2 is suggested to reflect the quality of CPR, predict the chance of spontaneous
return of circulation (ROSC), provide early warnings of re-arrest, and assist in neurologic prognostication after ROSC.21
Furthermore, cerebral oximetry has been employed to evaluate brain pressure autoregulation status. The cerebral oximetry
index (COx), a NIRS-based parameter, represents the correlation coefficient between mean arterial pressure and the slow
waves of ScO2. COx has been validated against other autoregulation parameters, such as the mean velocity index (Mx)
derived from transcranial Doppler measurements.22,23 Positive COx values indicate impaired autoregulation, while negative
values suggest preserved vasomotor response and autoregulation.24 Individualized bedside assessment of cerebral autoregu-
lation status, determination of optimal mean arterial pressure (MAP), and identification of the lower limit of pressure autoregu-
lation may allow personalized physiological management in the future.

SUMMARY
Cerebral oximetry aims to measure regional brain oxygenation to inform clinicians about the adequacy of cerebral per-
fusion. ScO2 serves as a surrogate marker for the balance between cerebral oxygen supply and demand and is most
effective when used as a trend monitor. Despite its promising role as a non-invasive neuromonitoring tool across vari-
ous clinical scenarios, routine use of cerebral oximetry is not yet supported by high-quality clinical data. Furthermore,
several technical challenges limit its widespread adoption.

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