Pressure-derived versus pressure wave amplitude–derived indices of cerebrovascular pressure reactivity in relation to early clinical state and 12-month outcome following aneurysmal subarachnoid hemorrhage

Clinical article

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Object

Indices of cerebrovascular pressure reactivity (CPR) represent surrogate markers of cerebral autoregulation. Given that intracranial pressure (ICP) wave amplitude–guided management, as compared with static ICP-guided management, improves outcome following aneurysmal subarachnoid hemorrhage (SAH), indices of CPR derived from pressure wave amplitudes should be further explored. This study was undertaken to investigate the value of CPR indices derived from static ICP–arterial blood pressure (ABP) values (pressure reactivity index [PRx]) versus ICP-ABP wave amplitudes (ICP-ABP wave amplitude correlation [IAAC]) in relation to the early clinical state and 12-month outcome in patients with aneurysmal SAH.

Methods

The authors conducted a single-center clinical trial enrolling patients with aneurysmal SAH. The CPR indices of PRx and IAAC of Week 1 after hemorrhage were related to the early clinical state (Glasgow Coma Scale [GCS] score) and 12-month outcome (modified Rankin Scale score).

Results

Ninety-four patients were included in the study. The IAAC, but not the PRx, increased with decreasing GCS score; that is, the higher the IAAC, the worse the clinical state. The PRx could differentiate between survivors and nonsurvivors only, whereas the IAAC clearly distinguished the groups “independent,” “dependent,” and “dead.” In patients with an average IAAC ≥ 0.2, mortality was approximately 3-fold higher than in those with an IAAC < 0.2.

Conclusions

The IAAC, which is based on single ICP-ABP wave identification, relates significantly to the early clinical state and 12-month outcome following aneurysmal SAH. Impaired cerebrovascular pressure regulation during the 1st week after a bleed relates to a worse outcome. Clinical trial registration no.: NCT00248690.

Abbreviations used in this paper:ABP = arterial blood pressure; CPP = cerebral perfusion pressure; CPR = cerebrovascular pressure reactivity; dP = amplitude; dT = rise time; dP/dT = rise time coefficient; GCS = Glasgow Coma Scale; IAAC = intracranial pressure–arterial blood pressure wave amplitude correlation; ICP = intracranial pressure; mRS = modified Rankin Scale; MWA = mean ICP wave amplitude; PRx = pressure reactivity index; SAH = subarachnoid hemorrhage; TCD = transcranial Doppler.

Article Information

Address correspondence to: Per Kristian Eide, M.D., Ph.D., Department of Neurosurgery, Oslo University Hospital–Rikshospitalet, PB 4950 Nydalen, 0424 Oslo, Norway. email: per.kristian.eide@ous-hf.no.

Please include this information when citing this paper: published online February 10, 2012; DOI: 10.3171/2012.1.JNS111313.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Graphs depicting the concept of CPR. Simultaneous ABP and ICP single pressure waves are automatically identified, and single wave amplitude (SW.dP) values are determined for every ICP-ABP single wave pair (A). During monitoring, the Pearson correlation coefficient of corresponding ICP-ABP single wave amplitudes (IAAC) is determined for consecutive 4-minute periods (B, Pearson correlation coefficient −0.06, p = 0.26; C, Pearson correlation coefficient 0.15, p = 0.009; and D, Pearson correlation coefficient 0.23, p = 0.009). Drawing (E) illustrating an intact CPR when the IAAC is low and an impaired CPR when the IAAC is more positive (tentatively ≥ 0.2).

  • View in gallery

    Graphs showing CPR indices derived from static PRx versus IAAC for the different categories of GCS score (A and D), best eye response (B and E), and best motor response (C and F). The significance of differences is shown (mixed model analysis).

  • View in gallery

    The average daily PRx (upper) and IAAC (lower) are plotted for Days 1–7 after ictus (Week 1) for independent (mRS Score 0–2, solid line), dependent (mRS Score 3–5, dotted and dashed line), and dead patients (mRS Score 6, dotted line). Error bars represent the 95% confidence interval.

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