Pressure autoregulation monitoring and cerebral perfusion pressure target recommendation in patients with severe traumatic brain injury based on minute-by-minute monitoring data

Clinical article

Bart Depreitere
Search for other papers by Bart Depreitere in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Fabian Güiza Intensive Care Medicine, University Hospitals Leuven, Belgium;

Search for other papers by Fabian Güiza in
Current site
Google Scholar
PubMed
Close
 Ph.D.
,
Greet Van den Berghe Intensive Care Medicine, University Hospitals Leuven, Belgium;

Search for other papers by Greet Van den Berghe in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Martin U. Schuhmann Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Germany; and

Search for other papers by Martin U. Schuhmann in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
,
Gottlieb Maier Klinik für Neurochirurgie, Universitätsklinikum Tübingen, Germany; and

Search for other papers by Gottlieb Maier in
Current site
Google Scholar
PubMed
Close
 M.D.
,
Ian Piper Clinical Physics, Southern General Hospital, Glasgow, United Kingdom

Search for other papers by Ian Piper in
Current site
Google Scholar
PubMed
Close
 Ph.D.
, and
Geert Meyfroidt Intensive Care Medicine, University Hospitals Leuven, Belgium;

Search for other papers by Geert Meyfroidt in
Current site
Google Scholar
PubMed
Close
 M.D., Ph.D.
Restricted access

Purchase Now

USD  $45.00

JNS + Pediatrics - 1 year subscription bundle (Individuals Only)

USD  $536.00

JNS + Pediatrics + Spine - 1 year subscription bundle (Individuals Only)

USD  $636.00
USD  $45.00
USD  $536.00
USD  $636.00
Print or Print + Online Sign in

Object

In severe traumatic brain injury, a universal target for cerebral perfusion pressure (CPP) has been abandoned. Attempts to identify a dynamic CPP target based on the patient's cerebrovascular autoregulatory capacity have been promising so far. Bedside monitoring of pressure autoregulatory capacity has become possible by a number of methods, Czosnyka's pressure reactivity index (PRx) being the most frequently used. The PRx is calculated as the moving correlation coefficient between 40 consecutive 5-second averages of intracranial pressure (ICP) and mean arterial blood pressure (MABP) values. Plotting PRx against CPP produces a U-shaped curve in roughly two-thirds of monitoring time, with the bottom of this curve representing a CPP range corresponding with optimal autoregulatory capacity (CPPopt). In retrospective series, keeping CPP close to CPPopt corresponded with better outcomes. Monitoring of PRx requires high-frequency signal processing. The aim of the present study is to investigate how the processing of the information on cerebrovascular pressure reactivity that can be obtained from routine minute-by-minute ICP and MABP data can be enhanced to enable CPPopt recommendations that do not differ from those obtained by the PRx method, show the same associations with outcome, and can be generated in more than two-thirds of monitoring time.

Methods

The low-frequency autoregulation index (LAx) was defined as the moving minute-by-minute ICP/MABP correlation coefficient calculated over time intervals varying from 3 to 120 minutes. The CPPopt calculation was based on LAx-CPP plots and done for time windows between 1 and 24 hours and for each LAx type. The resulting matrix of CPPopts were then averaged in a weighted manner, with the weight based on the goodness of fit of a U-shape and the lower value of the LAx corresponding to the U-bottom, to result in a final CPPopt recommendation. The association between actual CPP/CPPopt and outcome was assessed in the multicenter Brain Monitoring with Information Technology Research Group (BrainIT) database (n = 180). In the Leuven-Tübingen database (60-Hz waveform data, n = 21), LAx- and PRx-based CPPopts were compared.

Results

In the BrainIT database, CPPopt recommendations were generated in 95% of monitoring time. Actual CPP being close to LAx-based CPPopt was associated with increased survival. In a multivariate model using the Corticosteroid Randomization After Significant Head Injury (CRASH) model as covariates, the average absolute difference between actual CPP and CPPopt was independently associated with increased mortality. In the high-frequency data set no significant difference was observed between PRx-based and LAx-based CPPopts. The new method issued a CPPopt recommendation in 97% of monitoring time, as opposed to 44% for PRx-based CPPopt.

Conclusions

Minute-by-minute ICP/MABP data contain relevant information for autoregulation monitoring. In this study, the authors' new method based on minute-by-minute data resolution allowed for CPPopt calculation in nearly the entire monitoring time. This will facilitate the use of pressure reactivity monitoring in all ICUs.

Abbreviations used in this paper:

BrainIT = Brain Monitoring with Information Technology Research Group; CBF = cerebral blood flow; CPP = cerebral perfusion pressure; CPPopt = optimal CPP; CRASH = Corticosteroid Randomization After Significant Head Injury; DATACAR = Dynamic Adaptive Target of Active Cerebral Autoregulation; GOS = Glasgow Outcome Scale; ICP = intracranial pressure; IQR = interquartile range; LAx = low-resolution autoregulation index; L-PRx = low-frequency pressure reactivity index; MABP = mean arterial blood pressure; Mx = mean arterial Doppler flow velocity based autoregulation index; PRx = pressure reactivity index; RMSE = root mean squared error; TBI = traumatic brain injury.
  • Collapse
  • Expand
  • 1

    Aaslid R, , Lindegaard KF, , Sorteberg W, & Nornes H: Cerebral autoregulation dynamics in humans. Stroke 20:4552, 1989

  • 2

    Aries MJ, , Czosnyka M, , Budohoski KP, , Steiner LA, , Lavinio A, & Kolias AG, et al.: Continuous determination of optimal cerebral perfusion pressure in traumatic brain injury. Crit Care Med 40:24562463, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 3

    Bullock MR, & Povlishock JT: Guidelines for the management of severe traumatic brain injury, 3rd edition. J Neurotrauma 24:Suppl 1 S1S106, 2007

  • 4

    Chesnut RM, , Temkin N, , Carney N, , Dikmen S, , Rondina C, & Videtta W, et al.: A trial of intracranial-pressure monitoring in traumatic brain injury. N Engl J Med 367:24712481, 2012

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 5

    Czosnyka M, , Smielewski P, , Kirkpatrick P, , Laing RJ, , Menon D, & Pickard JD: Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery 41:1119, 1997

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 6

    Czosnyka M, , Smielewski P, , Kirkpatrick P, , Menon DK, & Pickard JD: Monitoring of cerebral autoregulation in head-injured patients. Stroke 27:18291834, 1996

  • 7

    Eker C, , Asgeirsson B, , Grände PO, , Schalén W, & Nordström CH: Improved outcome after severe head injury with a new therapy based on principles for brain volume regulation and preserved microcirculation. Crit Care Med 26:18811886, 1998

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 8

    Güiza F, , Depreitere B, , Piper I, , Van den Berghe G, & Meyfroidt G: Novel methods to predict increased intracranial pressure during intensive care and long-term neurologic outcome after traumatic brain injury: development and validation in a multicenter dataset. Crit Care Med 41:554564, 2013

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 9

    Howells T, , Elf K, , Jones PA, , Ronne-Engström E, , Piper I, & Nilsson P, et al.: Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg 102:311317, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 10

    Jaeger M, , Schuhmann MU, , Soehle M, & Meixensberger J: Continuous assessment of cerebrovascular autoregulation after traumatic brain injury using brain tissue oxygen pressure reactivity. Crit Care Med 34:17831788, 2006

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 11

    Johnson U, , Nilsson P, , Ronne-Engström E, , Howells T, & Enblad P: Favorable outcome in traumatic brain injury patients with impaired cerebral pressure autoregulation when treated at low cerebral perfusion pressure levels. Neurosurgery 68:714722, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 12

    Kellie G: Appearances observed in the dissection of two individuals; death from cold and congestion of the brain. Trans Med Chir Soc Edinb 1:84, 1824

  • 13

    Lam JM, , Hsiang JN, & Poon WS: Monitoring of autoregulation using laser Doppler flowmetry in patients with head injury. J Neurosurg 86:438445, 1997

  • 14

    Lodi CA, , Ter Minassian A, , Beydon L, & Ursino M: Modeling cerebral autoregulation and CO2 reactivity in patients with severe head injury. Am J Physiol 274:H1729H1741, 1998

    • PubMed
    • Search Google Scholar
    • Export Citation
  • 15

    Monro A: Observations on Structure and Functions of the Nervous System Edinburgh, Creech and Johnson, 1783

  • 16

    Perel P, , Arango M, , Clayton T, , Edwards P, , Komolafe E, & Poccock S, et al.: Predicting outcome after traumatic brain injury: practical prognostic models based on large cohort of international patients. BMJ 336:425429, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 17

    Piper I, , Citerio G, , Chambers I, , Contant C, , Enblad P, & Fiddes H, et al.: The BrainIT group: concept and core dataset definition. Acta Neurochir (Wien) 145:615629, 2003

  • 18

    Ragauskas A, , Daubaris G, , Petkus V, , Ragaisis V, & Ursino M: Clinical study of continuous non-invasive cerebrovascular autoregulation monitoring in neurosurgical ICU. Acta Neurochir Suppl 95:367370, 2005

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 19

    Robertson CS, , Valadka AB, , Hannay HJ, , Contant CF, , Gopinath SP, & Cormio M, et al.: Prevention of secondary ischemic insults after severe head injury. Crit Care Med 27:20862095, 1999

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 20

    Rosner MJ, & Daughton S: Cerebral perfusion pressure management in head injury. J Trauma 30:933941, 1990

  • 21

    Santos E, , Diedler J, , Sykora M, , Orakcioglu B, , Kentar M, & Czosnyka M, et al.: Low-frequency sampling for PRx calculation does not reduce prognostication and produces similar CPPopt in intracerebral haemorrhage patients. Acta Neurochir (Wien) 153:21892195, 2011

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 22

    Shaw M, , Piper I, , Chambers I, , Citerio G, , Enblad P, & Gregson B, et al.: The brain monitoring with Information Technology (BrainIT) collaborative network: data validation results. Acta Neurochir Suppl 102:217221, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 23

    Steiner LA, , Czosnyka M, , Piechnik SK, , Smielewski P, , Chatfield D, & Menon DK, et al.: Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med 30:733738, 2002

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 24

    Sviri GE, , Aaslid R, , Douville CM, , Moore A, & Newell DW: Time course for autoregulation recovery following severe traumatic brain injury. Clinical article. J Neurosurg 111:695700, 2009

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation
  • 25

    Tiecks FP, , Lam AM, , Aaslid R, & Newell DW: Comparison of static and dynamic cerebral autoregulation measurements. Stroke 26:10141019, 1995

  • 26

    Ursino M, & Giannessi M: A model of cerebrovascular reactivity including the circle of Willis and cortical anastomoses. Ann Biomed Eng 38:955974, 2010

  • 27

    Zweifel C, , Lavinio A, , Steiner LA, , Radolovich D, , Smielewski P, & Timofeev I, et al.: Continuous monitoring of cerebrovascular pressure reactivity in patients with head injury. Neurosurg Focus 25:4 E2, 2008

    • Crossref
    • PubMed
    • Search Google Scholar
    • Export Citation

Metrics

All Time Past Year Past 30 Days
Abstract Views 3796 1257 348
Full Text Views 1318 83 6
PDF Downloads 971 101 7
EPUB Downloads 0 0 0