British Journal of Anaesthesia 82 (3): 418–26 (1999)

REVIEW ARTICLE

Near infrared spectroscopy

H. Owen-Reece1, M. Smith1*, C. E. Elwell2 and J. C. Goldstone3

1Department of Neuroanaesthesia, National Hospital for Neurology and Neurosurgery, Queen Square,
London WC1N 3BG, UK. 2Department of Medical Physics and Bioengineering, University College London,
Capper Street, London WC1E 6JA, UK. 3Academic Department of Anaesthesia, University College London
Hospitals, Middlesex Hospital, Mortimer Street, London WC1N 8AA, UK
*To whom correspondence should be addressed

Br J Anaesth 1999; 82: 418–26

Keywords: monitoring, near infrared spectroscopy; brain, blood flow; brain, blood volume;
brain, near infrared spectroscopy
Accepted for publication: September 9, 1998

Despite significant advances in intensive care medicine, the

management of brain injured patients has been hampered
by the inability of clinicians to observe real-time changes
log [ ]
Io
I
5 a .c.d.

in cerebral haemodynamics and oxygenation at the bedside.
Near infrared spectroscopy (NIRS) has been used for this
purpose for many years in neonatal intensive care and has
the potential to be a monitor of cerebral well-being in
adult intensive care and anaesthesia, particularly in the
neurosciences. Although the principles underlying its use are
relatively straightforward, they are often poorly understood.
This review presents an overview of the physical prin-
ciples involved in the measurement of tissue oxygenation
with NIRS and describes how it may be used to continuously
observe changes in cerebral haemodynamics and oxygen-
ation. The clinical experience with NIRS is described in
addition to the techniques for non-invasive measurement of
cerebral blood flow (CBF) and cerebral blood volume
(CBV).
Physical principles
Absorption of light by coloured compounds
Light passing through a solution of a coloured compound
(or chromophore) is absorbed by the compound and the
intensity of the emerging light is therefore reduced. The
relationship between the concentration of a chromophore,
c, its extinction coefficient a (which describes the optical
characteristics of a compound at a given wavelength), the
thickness of solution, d, and the ratio of incident to emergent
Io
light intensity is given by the Beer–Lambert equation:
I potential of NIRS as a non-invasive monitor of cerebral
When light of a known wavelength is used to transilluminate
a solution of a compound of unknown concentration in vitro,
the extinction coefficient and thickness of solution traversed
can be substituted in the Beer–Lambert equation to derive
the concentration of the substance. Spectroscopy in this
form has been used for many years in colorimetric analysis
and, in certain circumstances, similar principles can be
applied to biological tissue.
Biological absorbers
Visible light (wavelength 450–700 nm) does not penetrate
biological tissue to a thickness greater than approximately
1 cm because it is strongly attenuated as a result of powerful
absorption and scattering by the tissue constituents. One of
the most significant absorbers of light is water which also
has a strong absorption at wavelengths of more than 900 nm.
However, there is a window of wavelengths in the near
infrared region between 650 and 900 nm in which photons
are able to penetrate tissue far enough to illuminate deeper
structures such as the cerebral cortex.9 47 In addition, there
are compounds in the tissues whose absorption of light
varies with their oxygenation status. In the near infrared
range, oxyhaemoglobin (HbO2), deoxyhaemoglobin (Hb)
and oxidized cytochrome oxidase (CytOx) have character-
istic absorption spectra.69 The concentrations of HbO2, Hb
and CytOx are likely to change rapidly during alterations
in cerebral perfusion and oxygenation, and a technique
allowing real-time measurements of these changes might
find a place as a monitor of cerebral well-being. The

© British Journal of Anaesthesia

 Near infrared spectroscopy
Fig 1 In a simple solution of a chromophore, light is absorbed; the detector
measures the difference in intensity between incident (Io) and emergent
(I) light. If the distance (d) through which the light passes is constant, the
absolute chromophore concentration (c) can be calculated from the Beer–
Lambert equation.
Fig 2 The light traversing the cuvette has been scattered by the solution.
Photon P1 travels on a path which is longer than the linear distance (d)
across the cuvette. Photon P2 passes through the solution but is lost from
the detector. For this reason, the ratio of incident to emergent light is not
a measure of absolute attenuation and cannot be used in the unmodified
Beer–Lambert law to measure absolute concentration.
oxygenation was first outlined by Jöbsis in 197733 and since
then it has found widespread application in neonatal and
adult medicine.
Effects of light scattering by tissue
The reason that the Beer–Lambert law in its simplest form
cannot be applied to tissue spectroscopy is because this
would require knowledge of absolute attenuation in order
to calculate absolute chromophore concentration (in this
case the absolute amounts of Hb, HbO2 and CytOx). As
tissue is a highly scattering medium, light is not only
attenuated by absorption but also by scattering away from
its original linear path. The actual quantity of light lost by
scattering is unknown. The following simple example makes
this clearer.
In Figure 1, attenuation (decrease in light intensity) is
caused entirely by absorption. That is, absorption is the
sole cause for emerging light to be less bright than incident
light. In Figure 2, attenuation is caused by both absorption
and scattering. Most light entering the head at a single point
is scattered in all directions and lost without being detected.
Total attenuation is therefore unknown and fully quantitative
spectroscopy cannot be performed using conventional sys-
419
tems. However, it can be assumed that tissue geometry
remains unchanged during a brief NIRS measurement and
because of this the degree of scattering is also unchanged.
In this way, the change in attenuation can be calculated
from the change in absorption, although the baseline value
remains unknown.
Differential pathlength factor
In addition to attenuation, tissue scattering has another
significant effect. The light has to travel further than the
straight line distance between the source and detector. In
order to quantify this change in chromophore concentration,
the distance which the light has actually travelled in the
tissue must be known, in the same way that cuvette thickness
must be known for simple spectroscopy (distance d in
Fig. 1). The increase in the distance travelled by each
photon because of scattering is expressed in terms of the
differential pathlength factor (DPF)9 which describes the
actual distance travelled by the light. In the normal adult
head, DPF is generally accepted to have a value of 6.3,10
that is light travels 6.3 times further than the straight line
path. With knowledge of this pathlength, the change in
chromophore concentration can be quantified in terms of
m mol/litre of tissue. In the simplest form therefore, tissue
spectrometers are able to display on a real-time basis, not
only changing concentrations of cerebral Hb and HbO2 but,
by simple addition, their sum, the total cerebral haemoglobin
(HbT) concentration. In most circumstances, HbT concen-
trations reflect CBV and can be converted into the more
conventional units of ml 100 g–1. Details of this conversion,
which include the molecular mass of haemoglobin, cerebral
to large vessel packed cell volume ratio, cerebral tissue
density and blood haemoglobin concentration have been
described elsewhere.70
Knowledge of the chosen value for DPF is crucial in
interpreting NIRS data. The DPF generally applied is
derived from studies in healthy adults10 and it should be
appreciated that it may vary in other situations and is also
wavelength dependent. DPF is 4.99 in neonatal brain, 5.51
in the adult leg and 4.16 in the adult arm, using light of
wavelength 807 nm.10 Additionally, the effect of patho-
logical situations, such as cerebral oedema or ischaemia,
have not been investigated and clinical work to date uses
one of the quoted ‘normal’ values. DPF may also change
within the same subject over a period of time if the state
of the tissue (e.g. water content) or tissue geometry alters,
although both are unlikely during the relatively brief period
during which most NIRS measurements are made. New
generation apparatus may allow real-time measurement of
DPF thereby removing any potential errors generated by
the use of an estimated value.9
Algorithms
In order to derive concentration changes simultaneously
for Hb, HbO2 and CytOx, values for absorption at four
wavelengths of near infrared light are often used. The
 Owen-Reece et al.
calculation used to solve the modified Beer–Lambert equa-
tion at each of these wavelengths is known as an algorithm.
Several algorithms have been published and these vary
depending on the wavelengths of light used, presence of
other chromophores and the precise values for absorption
coefficients chosen.28 58 67 Recent work has applied different
published algorithms to the same data set and revealed
striking differences in the calculated concentration
changes.42 It is clearly important that the algorithm is known
when NIRS data, collected using different equipment, are
presented.
Although the absorption coefficient for CytOx is approxi-
mately twice as great as that for haemoglobin, the tissue
concentration is at least one order of magnitude less.60 The
signal from CytOx is also more dependent on the algorithm
than that from haemoglobin and for this reason too, caution
must be used in interpreting NIRS-derived CytOx measure-
ments. In comparison, the signal for haemoglobin is much
more robust.
Comparison of NIRS with pulse oximetry
Confusion often occurs in respect of differences between
NIRS and pulse oximetry. There are three fundamental
differences.
(i) Different wavelengths are used in the two techniques
and NIRS therefore has far greater tissue penetration than
pulse oximetry.
(ii) Pulse oximetry deliberately considers only the arterial
compartment by time gating the measurements. It calculates
the ratio of HbO2 to (Hb1HbO2) on the pulsatile component
and displays it as SpO2. NIRS does not discriminate in this
way and provides a global assessment of oxygenation in
all vascular compartments (arterial, venous and capillary).
(iii) NIRS uses more wavelengths for spectroscopic transil-
lumination and can therefore characterize more chromo-
phores than pulse oximetry.
Equipment design
There are a variety of commercially available equipment
which allow tissue spectroscopy. It should be noted that
there is a difference in the manner in which NIRS is applied
to measure cerebral changes in neonates and adults. In
neonates, the thin skull and small head allows light to be
shone through the whole head and transmission spectro-
scopy is possible. In adults however, the large head and thick
skull require reflectance spectroscopy where the transmitting
and receiving optodes are placed a few centimetres apart
on the same side of the head. The algorithms used to
derive chromophore concentrations are equally valid for
measurements made in both situations.
There are basic features common to all commercially
available NIRS equipment. Light is generated at specific
wavelengths by laser photodiodes which can be detected
either by a photomultiplier tube (PMT)7 or, in more recent
equipment, by a silicon photodiode.5 32 A computer then
420
converts the changes in light attenuation to changes in
chromophore concentration. Beyond this stage, two distinct
methods of data handling can be described. They are
fundamentally different but frequently confused and data
from the two methods are often presented as though they
were interchangeable. The performance of two commer-
cially available spectrophotometers using these different
approaches has recently been compared.48
(1) Non-quantitative measurements—cerebral
oximetry
Cerebral saturation can be measured using techniques which
avoid fully quantifying changes in haemoglobin concentra-
tion. The INVOS 3100 (Somanetics, MI, USA) measures
the ratio of light absorption by HbO2 and HbT, and from
it calculates a value for mean cerebral saturation, thus
avoiding quantification of change in haemoglobin concentra-
tion. Human studies using the first commercial version were
published in 1991.45 46 The technique uses a two-wavelength
near infrared source, emitting light which is detected by
two receivers. In the original version, one was at 1.0 cm
and the other 2.7 cm from the light source. The transmitter
and receivers are arranged in a linear fashion such that the
light arriving at the proximal receiver is considered to have
passed largely through non-cerebral surface tissues whereas
the distal receiver detects light also passing through brain
tissue. If the signal received by the proximal receiver is
subtracted from that of the distal receiver, the ratio of the
two gives a mean value for cerebral oxygen saturation.
McCormick and colleagues demonstrated that it was pos-
sible to measure regional cerebrovascular oxygen saturation
with this arrangement.45
Others have had some difficulty in replicating these
results. For example, Harris and Bailey produced an increase
in middle cerebral artery blood flow velocity measured
using transcranial Doppler by inducing hypercapnia, but
were unable to demonstrate a change in regional cerebral
oxygen saturation.27 Similarly, Lewis and co-workers38
demonstrated that regional cerebral oxygenation measured
by the INVOS did not reflect significant changes in cerebral
oxygenation detected by the global measurement of jugular
venous bulb oxygen saturation (SjO2). These results are
difficult to explain but may be a result in part to inadequate
inter-optode separation. In a study during carotid angio-
graphy, four receivers were placed on the scalp at separations
from the transmitter of 1.5, 2.5, 3.5 and 4.5 cm. When a
bolus of the infrared absorber indocyanine green was
injected into the internal carotid artery, relative absorption
increased with detector distance from the light source but
no substantial difference in attenuation was observed in any
of the detectors during external carotid injection.31 Direct
DPF measurements have also shown that with inter-optode
distances of less than 2.5 cm, it cannot be assumed in adults
that DPF will have a predictable value, as with small inter-
optode spacings the surface tissues have a disproportionate
effect on light transport and light will not reliably penetrate
 Near infrared spectroscopy
the cortex.65 As most of the near infrared light travels along
an extracranial path when the source–detector separation is
less than 2.5 cm, it is important to use the maximum inter-
optode spacing compatible with adequate light detection.
In adults, an inter-optode spacing of 4 cm is now typically
used by most investigators.
Cerebral saturation values measured with the INVOS
have been compared with SjO2.24 These authors recorded a
change in cerebral oxygen saturation of 3.6% for every
10% change in SjO2 and also confirmed that extracranial
tissues had a negligible effect on cerebral saturation values.
Finally, in a pragmatic approach to the problem of variability
of the value for cerebral oxygen saturation provided by the
INVOS, Schwartz and colleagues made measurements in
18 dead subjects.61 They found that mean saturation was
51 6 27% compared with 68 6 5% in a group of normal
healthy controls. Six of the 18 dead subjects had a value
greater than the lowest values for healthy adults. As the
algorithms for the INVOS are not published, it is difficult
to make meaningful comparisons with data generated by
other equipment.
A newer version of the INVOS, with a larger source–
detector separation (3–4 cm), is now available and greater
sensitivity to intracerebral events is claimed. Work with this
equipment has demonstrated that scalp ischaemia induced by
a pneumatic tourniquet results in a decrease in measured
regional cerebral oxygen saturation, suggesting that the
inbuilt compensation for the effect of extracerebral tissues
is still inadequate.23 However, this study confirms that when
scalp ischaemia is established, cerebral saturation varies
with arterial saturation, suggesting sensitivity of the device
for intracranial events. This apparatus has also been used
successfully to detect cerebral hypoxia during carotid endar-
tectomy,68 but others have failed to show a relationship
between regional cerebral saturation measured by the
INVOS and jugular bulb oximetry in comatose patients
after cardiac arrest.6
(2) Quantitative concentration measurements
The second category of NIRS equipment allows full quanti-
fication of changes in chromophore concentration and
maximizes the potential of tissue spectroscopy. Equipment
allowing this has been developed by several manufacturers,
including Hamamatsu Photonics (Hamamatsu City, Japan),
Critikon (Ascot, Berkshire, UK) and Radiometer
(Copenhagen, Denmark). These quantitative data, although
from an unknown baseline, have formed the basis for
several studies. Early clinical studies, which did not take
account of pathlength, observed changes in cerebral HbO2,
Hb and CytOx concentrations in adults20 and neonates19
and in these same chromophores during skeletal muscle
ischaemia.26 Subsequently, several studies which incorpor-
ate DPF have been carried out. These demonstrate that
changes in cerebral haemodynamics in preterm infants
can be observed after alterations in arterial PaCO271 and
administration of indomethacin12 and surfactant.13 It has
421
also been demonstrated that it is possible to measure changes
in CBV in response to alterations in PaCO2 in adults53 and
during cardiopulmonary bypass in children.18 Changes in
cerebral haemodynamics with varying end-expiratory pres-
sure,16 tilting41 and induction of anaesthesia40 have also
been documented. Furthermore, neurological status after
cardiac surgery has been compared with intraoperative
measurements of cerebral oxygenation.50 Cerebral haemo-
dynamic changes measured by NIRS have been correlated
with peripheral oxygen desaturation, intracranial hyperten-
sion and cerebral hyperaemia in a group of head-injured
patients.35 NIRS was able to detect correlated changes in
97% of events whereas SjO2 registered changes in only 53%.
The authors commented on the apparent high sensitivity of
NIRS compared with SjO2 monitoring. Finally, it has been
demonstrated that intrapartum changes in fetal Hb, HbO2
and HbT concentrations can be monitored effectively using
an NIRS probe attached transvaginally to the fetal head.1 57
NIRS apparatus allowing quantification of changes in
haemoglobin concentration can also be used to calculate
cerebral saturation in a variety of ways. One approach is
to induce brief, small changes in CBV by digital occlusion
of one jugular vein.72 The resultant changes in HbO2
concentration can be divided by the changes in HbT
concentration to give a measure of cerebral haemoglobin
saturation during the period of blood volume change. Two
studies have compared measurements at different values of
arterial oxygen saturation17 or arterial PaCO2.56 A particular
advantage of measuring cerebral saturation with this method
is that being a ratio of two concentrations, the variable is
free of the potential errors introduced using a differential
pathlength factor.
Another NIRS system which provides an absolute meas-
urement of tissue haemoglobin saturation has been described
recently.43 The spatially resolved spectrometer (SRS)
incorporates several detectors housed in a single probe
which is placed 4–5 cm from the source. Combination of
these multi-distance measurements of optical attenuation
with the usual multi-wavelength spectroscopy data allows
calculation of the relative concentrations of Hb and HbO2
in the illuminated tissue and therefore an estimate of mean
tissue haemoglobin saturation. It is possible to follow trends
in cerebral oxygenation with this apparatus although it
appears to underestimate the absolute mean cerebral satura-
tion compared with other methods.17
Finally, absolute cerebral saturation may be measured
using a phase shift technique. If laser light oscillating at a
known frequency is used to transilluminate the head, the
emerging light is out of phase with the incident light. This
phase shift is directly proportional to the actual pathlength
of light through the tissue sample and is wavelength specific.
Such phase shift measurements allow absorption and scat-
tering to be quantified and calculation of absolute changes
in cerebral HbO2 and Hb concentrations and saturation.36
One clinical study has attempted to correlate changes in
cerebral saturation measured by this method with the onset
 Owen-Reece et al.
of neuronal ischaemia assessed by EEG changes.39 In
a group of subjects undergoing testing of implantable
defibrillators, mean cerebral saturation was measured as
56.5% and the cerebral ischaemic threshold estimated at
47%. A relationship between the onset of cerebral desatura-
tion measured by NIRS and cerebral ischaemia as assessed
by EEG changes was demonstrated.
It is important that the significance of changes in HbO2
and Hb concentrations from an unknown baseline are not
misunderstood. In an article comparing jugular venous bulb
oxygen saturation with changes in cerebral HbO2 and Hb
concentrations, the authors commented that an increase in
SjO2 (in response to an increase in PaCO2) from 63% to
76% was accompanied by an increase in cerebral HbO2
concentration of 3.5 m mol litre–1 (of brain tissue) and a
decrease in Hb concentration of 1.5 m mol litre–1.64 It is
spurious to make this comparison without a knowledge of
the actual baseline values for HbO2 and Hb concentrations
and these cannot be measured presently. In the above study,
an increase in HbO2 concentration of 3.5 m mol litre–1 from,
for example, baseline values of 350 or 35 m mol litre–1
would represent actual increases of 1% or 10%, respectively.
This again emphasizes the care needed in interpreting
NIRS data.
Clinical applications
NIRS can be used as a continuous monitor of changes in
cerebral oxygenation and blood volume by following
changes in the concentrations of HbO2 and HbT. It is also
possible to make absolute measurements of cerebral blood
flow and volume.
Measurement of cerebral oxygenation
A reliable method for detection of cerebral oxygen desatura-
tion is required.35 Jugular venous bulb oxygen saturation
monitoring is invasive and prone to artefact, even in
experienced hands.2 A high percentage of SjO2 readings are
discarded as erroneous and significant desaturations may
be missed because of complications associated with the
catheter and its placement.8 More recently, multi-parameter
probes have been inserted into the brain to allow direct
measurement of tissue PO2, PCO2 and pH.73 74 However,
these techniques are restricted to specialist centres because
of their invasive nature, and clinical experience is limited.
In contrast, NIRS offers the potential for non-invasive
monitoring of changes in cerebral oxygenation and the
clinical application of NIRS in this area has already been
discussed.
Measurement of cerebral haemodynamics
Traditional methods of examining CBF and CBV also tend
to be rather invasive. 133Xenon washout51 and positron
emission tomography (PET)37 use radioactive tracers and
require either i.v. or intra-arterial access, or both. The
Kety–Schmidt technique has similar requirements.34 PET,
422
Fig 3 Measurement of cerebral blood flow. The lower trace shows the
change in cerebral HbO2 concentration measured using NIRS with optodes
placed directly on the dura. The upper trace shows simultaneous changes
in SpO2 recorded by a pulse oximeter placed on the ear lobe. After a brief
period of reduced SpO2, administration of 100% oxygen (arrow) results in
a rapid increase in SpO2 to normal (upper trace). NIRS measures directly
the associated flow of HbO2 into the brain (lower trace).
although arguably the gold standard, requires not only a
scanning suite but also an on-site cyclotron for nuclide
generation.37 Transcranial Doppler measures cerebral blood
flow velocity, but has the limitation that observed changes
in velocity may be caused by changes in calibre of the
insonated vessel as well as blood flow.3 A non-invasive,
bedside technique for measuring CBF or CBV would have
clear advantages. Despite the inherent problems of NIRS,
the potential applications of the technique are becoming
clearer. Methods of using NIRS to achieve ‘absolute’
quantification of CBF and CBV have been developed in
neonatal intensive care11 70 and have more recently been
applied in adult medicine.15 53 54
(a) Measurement of cerebral blood flow
NIRS has been applied to the measurement of tissue blood
flow by using a small change in HbO2 concentration as a
tracer and applying a modification of the Fick principle.
This elegant method of measuring CBF was first described
in neonates by Edwards and colleagues in 1988.11 A small
reduction in arterial saturation (of the order of 5%) is
induced by lowering FIO2. When a stable baseline is
achieved, a breath of 100% oxygen creates a bolus of HbO2
in the arterial circulation which acts as the required Fick
tracer (Fig. 3). The rate of arrival of HbO2 in the brain a
few seconds later can be observed by NIRS. CBF may be
calculated by considering the ratio of the rate of tracer
accumulation in the organ to the amount of tracer delivered.
The accumulation of HbO2 in the brain is dependent
on both arterial inflow and venous outflow. However, if
measurements are made within the cerebrovascular transit
time (,4 s) venous outflow can be considered to be zero
and the measured increase in HbO2 concentration can be
assumed to be entirely a result of arterial inflow of the
tracer. The amount of tracer delivered is given by the
 Near infrared spectroscopy
integral of the change in SpO2 multiplied by the concentration
of haemoglobin in blood. Changes in HbO2 concentration
are measured by NIRS in m mol litre–1 but it is possible to
convert calculated CBF into units of ml 100 g–1 min–1. The
theory and details of such calculations have been dealt with
extensively elsewhere.14 15
Several assumptions are made in the calculation of CBF
with NIRS. First, it is assumed that cerebral metabolic rate,
blood flow and volume remain constant during the short
period of measurement and therefore that HbO2 is truly
acting as an inert tracer. Studies in animals and humans
have shown that CBF and oxygen extraction do not alter
with changes in PaO2 between 6.5 and 13 kPa62 and this
range greatly exceeds the variation in PaO2 required for this
technique.
There may be a delay between NIRS and pulse oximeter
signals and this can be minimized by placing the oximeter
on the earlobe. It is also necessary to use a pulse oximeter
with minimal signal averaging. The extensive data
smoothing which is applied to most commercially available
instruments results in loss of resolution of rapid changes in
arterial saturation which occur beat-by-beat and which must
be used for the accurate calculation of CBF over 4 s.
The effect of arterial desaturation on PaO2 is also of
crucial importance, not only for the safety of the patient
but also for the validity of the technique. The fact that
oxygen extraction is not altered until a PaO2 of 6.5 kPa is
reached (which is well below the level attained during a
CBF measurement) is the strongest evidence that there is
no significant effect on tissue metabolism at a PaO2 above
this value. This provides considerable reassurance that
the desaturation–resaturation technique, as described, is
innocuous to cerebral well-being. Nevertheless, there is a
natural preference to avoid any degree of hypoxaemia,
however brief. In some circumstances, it is possible to use
indocyanine green in a similar way and excellent preliminary
results have been obtained during cardiopulmonary
bypass.59
Application of this technique in the clinical field was
demonstrated by Edwards and colleagues who showed that
i.v. indomethacin administered to close a patent ductus
arteriosus led to a marked decrease in CBF measured by
NIRS.12 Furthermore, in a group of babies who had suffered
anoxic–ischaemic insults at birth, an elevated CBF and
CBV and reduction in the response of CBV to carbon
dioxide have been described.44
(b) Measurement of cerebral blood volume
Notwithstanding that CBF is the haemodynamic variable
most familiar to clinicians, a combination of this information
with other variables such as CBV would be valuable in
interpreting changes in the clinical condition. Continuous
measurement of changes in HbT concentration generally
reflects changes in CBV. A recent study has confirmed that
real-time changes in CBV can be demonstrated with NIRS
during changes in posture.41
423
Fig 4 Calculation of cerebral blood volume. Arterial saturation is altered
and the change in HbO2 concentration is plotted against the change in
SpO2. The gradient of the resulting straight line is proportional to the
quantity of haemoglobin in the illuminated tissue.
Absolute quantification of CBV is also possible with
NIRS.70 If arterial saturation is reduced by a small increment
(approximately 5%) in a slow and controlled manner (in
order to allow full equilibration within the whole of the
cerebral microcirculation) HbO2 concentration is observed
by NIRS to decline in parallel. As with CBF measurement,
it is important that the change is small enough to avoid any
effects on CBF or oxygen extraction. If arterial saturation
is plotted against HbO2 concentration, the gradient of the
resulting straight line is directly proportional to CBV
(Fig. 4).
Consider a brain empty of blood. However much arterial
saturation was varied, there could be no change in cerebral
HbO2 concentration and the gradient of the line would be
zero. In contrast, a head with a high CBV would display a
large change in HbO2 concentration for a small change in
arterial saturation.
As the units of the gradient (m mol litre–1 of haemoglobin)
are unfamiliar in the raw state it must be converted to CBV
in the same way as described for HbT. This measurement
can be used to provide a baseline value for CBV with
which the real-time trends in HbT concentration can be
compared.
Validity of measured variables
Comparisons of NIRS derived cerebral saturation and
jugular venous bulb oxygen saturation are commonly
made,6 24 38 45 56 64 but it should be remembered that these
techniques are examining different vascular compartments.
NIRS interrogates arterial, venous and capillary blood and
therefore the derived saturation is a mean value for these
three compartments. Although the majority of the contribu-
tion to the NIRS signal is likely to be from venous blood
(as it contributes approximately 70% of intracranial blood
volume) there is no way of determining the absolute
contribution of each of these compartments to the calculated
mean value for cerebral saturation. However, the NIRS
method of measuring cerebral saturation which relies on
inducing changes only in the venous compartment by digital
 Owen-Reece et al.
occlusion of the jugular vein, as described above,72 is more
likely to be comparable with changes in jugular venous
oxygen saturation.
There has also been considerable speculation on the area
of brain, both topographically and functionally, that is being
interrogated by NIRS. Computer modelling can demonstrate
the area of brain illuminated and has shown that this is
subject to significant influence from fluid–tissue interfaces
in the illuminated region.21 52 In adults, the optodes are
generally placed on the forehead for reasons of accessibility
and this represents the anterior cerebral circulation. How-
ever, in neonates it is obvious that most of the head is
illuminated by the beam of light crossing it and the NIRS
signal is more representative of one or both hemispheres.
Much of the early work on quantification of haemo-
dynamic variables was carried out in neonates. As the non-
cerebral tissue of the head is so much thinner in preterm
infants than in adults there are fewer problems with light
loss in the scalp and skull. For this reason the method of
CBF measurement described gives measured values for
CBF which correspond with those simultaneously measured
by 133xenon washout.4 63 Although the correlation is good
at low to normal values, there is a tendency for CBFNIRS
to overestimate CBFXe at high flows.63 Furthermore, the
coefficient of variability for CBFNIRS in both infants63 and
adults14 is greater than for 133xenon. This means that it is
necessary to make several measurements in order to obtain
a reliable mean value for CBF. However, the non-invasive
nature of NIRS compared with other methods of measuring
CBF is an enormous advantage which may offset the greater
variability.
At present, NIRS methods in adults strikingly underesti-
mate CBF54 and this is likely to relate to the contribution
of non-cerebral tissue overlying the cerebral tissue in the
field of view. The head is not opaque to infrared light, but
scatters the light very intensely and computer modelling
has shown that in a typical volume of tissue interrogated
by NIRS, approximately 30% is brain and 70% is non-
cerebral (i.e. scalp and skull).29 Although the DPF applies
to the entire illuminated tissue volume and its scattering
properties, because extracerebral blood flow is low,22 only
30% of the illuminated volume has a rapidly varying HbO2
concentration when SpO2 is altered during CBF and CBV
measurements. It is probably for this reason that NIRS-
derived CBF and CBV in the adult subject have values
approximately 70% less than those predicted by other
techniques. This is confirmed by a study which showed
that, whereas mean CBF was measured as 67 ml 100
g–1 min–1 when the optodes were placed directly on the
dura, the value was only 23 ml 100 g–1 min–1 when
measured transcranially in the same subjects.54 However, a
more recent study has demonstrated a value for CBV much
closer to the expected range25 and the relationship between
transcranial NIRS measurements of CBV and CBF and the
values obtained using other methods is still far from clear.
In an attempt to examine the contribution of scalp blood
424
flow to the NIRS signal, Owen-Reece and colleagues
measured CBV in nine adults before and after inflating a
pneumatic tourniquet proximal to the NIRS measurement
site.55 Because a change in scalp blood content could
potentially change the pathlength of light passing through
the head, the optical pathlength was also measured before
and after tourniquet inflation. Occlusion of scalp blood flow
had no effect on DPF or the measured value for CBV. It
was concluded that, provided the distance between light
entry and exit on the scalp is sufficiently large, changes in
scalp blood flow have no effect on NIRS measurements of
cerebral haemodynamics.
Future developments
The principal problem affecting NIRS in adult medicine is
the effect of extracerebral tissue to scatter light and decrease
the magnitude of the measurements. The contribution of
these layers is still unclear but the use of increasingly
sophisticated computer modelling will permit a better under-
standing of these effects. Furthermore, with modern equip-
ment it will be possible to make real-time correction of the
scattering effects of extracerebral tissue.
It is obvious that the non-invasive nature of NIRS is its
main advantage. The equipment is also suitable for use at
the bedside, thereby avoiding the necessity to transfer
critically ill patients to remote scanning suites. A third asset
is that no radionuclides are required. Finally, the data are
provided on a real-time basis as often as twice a second.
The variety of data which can be measured by NIRS
(real-time cerebral oxygenation and CBV changes, and
absolute CBV and CBF measurements) contributes to its
potential. An exciting new development is the application
of NIRS in functional imaging. Changes in HbO2 concentra-
tion can be detected over the occipital cortex in adults in
response to visual stimulation49 66 and over the frontal
cortex in response to calculation tasks.30
It is important that simple technical details such as optode
designs which reduce sensitivity to movement and the
effects of ambient light are appreciated, as commercial
equipment is in a relatively early stage of development.
The problem of changing source–detector separation during
the course of a measurement is also being addressed; if this
distance changes, the resulting changes in attenuation are
not easy to differentiate from concentration changes. The
next generation of equipment will allow measurement of
total optical pathlength and compensation for the movements
which inevitably occur during clinical use.
NIRS techniques in adults remain only promising pos-
sibilities at present, but steady progress is being made in
their development. It is clear that a bedside monitor of
cerebral well-being will be invaluable. Commercial pressure
to produce a marketable NIRS monitor is intense but it is
important that this pressure does not compromise the
requirement to validate the use and reliability of NIRS
before its widespread release into clinical practice.
 Near infrared spectroscopy
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