Asymmetry of pressure autoregulation after traumatic brain injury

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Object. The aim of this study was to assess the asymmetry of autoregulation between the left and right sides of the brain by using bilateral transcranial Doppler ultrasonography in a cohort of patients with head injuries.

Methods. Ninety-six patients with head injuries comprised the study population. All significant intracranial mass lesions were promptly removed. The patients were given medications to induce sedation and paralysis, and artificial ventilation. Arterial blood pressure (ABP) and intracranial pressure (ICP) were monitored in an invasive manner. A strategy based on the patient's cerebral perfusion pressure (CPP = ABP − ICP) was applied: CPP was maintained at a level higher than 70 mm Hg and ICP at a level lower than 25 mm Hg. The left and right middle cerebral arteries were insonated daily, and bilateral flow velocities (FVs) were recorded. The correlation coefficient between the CPP and FV, termed Mx, was calculated and time-averaged over each recording period on both sides. An Mx close to 1 signified that slow fluctuations in CPP produced synchronized slow changes in FV, indicating a defective autoregulation. An Mx close to 0 indicated preserved autoregulation. Computerized tomography scans in all patients were reviewed; the side on which the major brain lesion was located was noted and the extent of the midline shift was determined. Outcome was measured 6 months after discharge. The left—right difference in the Mx between the hemispheres was significantly higher in patients who died than in those who survived (0.16 ± 0.04 compared with 0.08 ± 0.01; p = 0.04). The left—right difference in the Mx was correlated with a midline shift (r = −0.42; p = 0.03). Autoregulation was worse on the side of the brain where the lesion was located (p < 0.035).

Conclusions. The left—right difference in autoregulation is significantly associated with a fatal outcome. Autoregulation in the brain is worse on the side ipsilateral to the lesion and on the side of expansion in cases in which there is a midline shift.

Article Information

Address reprint requests to: Marek Czosnyka, Ph.D., Academic Neurosurgery Unit, P. O. Box 167, Addenbrooke's Hospital, Hills Road, Cambridge CB2 2QQ, United Kingdom. email: mc141@medschl.cam.ac.uk.

© AANS, except where prohibited by US copyright law.

Headings

Figures

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    Left: Traces demonstrating asymmetry of autoregulation. The dash—dot-bordered rectangle isolates an example of the difference in the behavior of FVs. The MFVr (FVr) follows the CPP closely, indicating a defective autoregulation; the MFVl (FVl) does not passively change with the CPP and thus autoregulation is preserved. Right: Graphs showing the results of the regression analyses in which the MFVl was compared with the CPP and the MFVr was compared with the CPP. The Pearson correlation coefficient is shown for each analysis. On the patient's left side, changes in CPP do not produce changes in MFVl; the Pearson coefficient (Mx) is a negative number close to zero, indicating that autoregulation is efficient. On the patient's right side, changes in CPP produce changes in MFVr; the Mx is positive, signifying that autoregulation is defective.

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    Upper: Scatterplot showing a comparison between the Mxl and the Mxr. The linear regression is displayed as a solid line and the Pearson correlation coefficient and significance level are indicated on the graph. Lower: Scatterplot showing a comparison between the left—right Mx and the left—right difference in the Mx. The solid horizontal lines indicate the upper and lower 95% confidence boundaries (± 0.18) for the left—right difference in the Mx in healthy volunteers.

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    Upper: Scatterplot showing a comparison between the left—right difference in the Mx and the midline shift. The linear regression is displayed as a solid line and the Pearson correlation coefficient and significance level are indicated on the graph. Lower: Diagram illustrating the meaning of the scatterplot. Schematic heads representing a midline shift to each side are displayed. When there is a midline shift, our data show that autoregulation is worse on the side of cerebral expansion.

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