Continuous Monitoring of Cerebrovascular Reactivity Using Pulse Waveform of Intracranial Pressure

Aries, Marcel; Czosnyka, Marek; Budohoski, Karol P.; Kolias, Angelos G.; Radolovich, Danila K.; Lavinio, Andrea; Pickard, John D.; Smielewski, Peter

doi:10.1007/s12028-012-9687-z

Cited by 98 publications

(82 citation statements)

References 25 publications

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“…These variable thresholds yielded superior outcome prediction than fixed thresholds of 20 or 25 mmHg. In the context of our findings, which show a time-dependent ICP threshold that usually remains below 20 mmHg, pulse amplitude index (PAx—correlation between pulse amplitude of ICP and MAP) may be superior for the latter strategy, as it is proven to be a superior outcome predictor than PRx at ICP < 20 mmHg [4]. …”

Section: Discussionmentioning

confidence: 99%

Critical thresholds for intracranial pressure vary over time in non-craniectomised traumatic brain injury patients

et al. 2018

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BackgroundIntracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-guided therapy is central to neurocritical care for traumatic brain injury (TBI) patients. We sought to identify time-dependent critical thresholds for mortality and unfavourable outcome for ICP and CPP in non-craniectomised TBI patients.MethodsThis is a retrospective cohort study of 355 patients with moderate-to-severe TBI who received ICP monitoring and were managed without decompressive craniectomy in a tertiary hospital neurocritical care unit. Patients were grouped in 2 × 2 tables according to survival/death or favourable/unfavourable outcomes at 6 months and serial thresholds of mean ICP and CPP, using increments of 0.1 and 0.5 mmHg respectively. Sequential chi-square analysis was performed, and the thresholds yielding the highest chi-square test statistic were taken as having the best discriminative value for outcome. This process was repeated over monitoring periods of 1, 3, 5 and 7 days and for each day of recording to establish time-dependent thresholds. The same analysis was performed for age and sex subgroups.ResultsGlobal ICP thresholds were 21.3 and 20.5 mmHg for mortality and unfavourable outcome respectively (p < 0.001). After the first day of ICP monitoring, ICP thresholds fell to between 15 and 20 mmHg and remained significant (p < 0.05). Significant time-dependent CPP thresholds for mortality or unfavourable outcome were often not identified, and no identifiable trends were produced.ConclusionCritical ICP thresholds in non-craniectomised TBI patients vary with time and fall below established ICP targets after the first day of monitoring.Electronic supplementary materialThe online version of this article (10.1007/s00701-018-3555-3) contains supplementary material, which is available to authorized users.

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Section: Discussionmentioning

confidence: 99%

Critical thresholds for intracranial pressure vary over time in non-craniectomised traumatic brain injury patients

et al. 2018

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“…A study on this issue is thus far missing. However, there are data indicating that in situations with high brain compliance, for example, following surgery, the PRx may not be an ideal parameter, suggesting a different index PAx as an alternative, especially in situations with lower ICP [17]. Furthermore, a non-invasive alternative for continuous determination of cerebrovascular reactivity and CPPopt may be the near-infrared spectroscopy based index THx.…”

Section: Discussionmentioning

confidence: 99%

“…However, the applicability of THx in the setting of high brain compliance has not been addressed. Furthermore, the correlation between the autoregulation indices varies around 0.5 [18] and 0.6 [17], indicating that different techniques may represent distinct aspects of cerebrovascular reactivity and autoregulation. So far, the PRx remains the best studied parameter, especially with respect to calculation of CPPopt and probably would be the parameter of choice in a prospective trial on CPPopt management.…”

Section: Discussionmentioning

confidence: 99%

Optimal cerebral perfusion pressure in patients with intracerebral hemorrhage: an observational case series

et al. 2014

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IntroductionCurrent guidelines for spontaneous intracerebral hemorrhage (ICH) recommend maintaining cerebral perfusion pressure (CPP) between 50 and 70 mmHg, depending on the state of autoregulation. We continuously assessed dynamic cerebral autoregulation and the possibility of determination of an optimal CPP (CPPopt) in ICH patients. Associations between autoregulation, CPPopt and functional outcome were explored.MethodsIntracranial pressure (ICP), mean arterial pressure (MAP) and CPP were continuously recorded in 55 patients, with 38 patients included in the analysis. The pressure reactivity index (PRx) was calculated as moving correlation between MAP and ICP. CPPopt was defined as the CPP associated with the lowest PRx values. CPPopt was calculated using hourly updated of 4 hour windows. The modified Rankin Scale (mRS) was assessed at 3 months and associations between PRx, CPPopt and outcomes were explored using Pearson correlation and Fisher’s exact test. Multivariate stepwise logistic regression models were calculated including standard outcome predictors along with percentage of time with PRx >0.2 and percentage of time within the CPPopt range.ResultsAn overall PRx indicating impairment of pressure reactivity was found in 47% of patients (n = 18). The mean PRx and the time spent with a PRx > 0.2 significantly correlated with mRS at 3 months (r = 0.50, P = 0.002; r = 0.46, P = 0.004). CPPopt was calculable during 57% of the monitoring time. The median CPP was 78 mmHg, the median CPPopt 83 mmHg. Mortality was lowest in the group of patients with a CPP close to their CPPopt. However, for none of the CPPopt variables a significant association to outcome was found. The percentage of time with impaired autoregulation and hemorrhage volume were independent predictors for acceptable outcome (mRS 1 to 4) at three months.ConclusionsFailure of pressure reactivity seems common following severe ICH and is associated with unfavorable outcome. Real-time assessment of CPPopt is feasible in ICH and might provide a tool for an autoregulation-oriented CPP management. A larger trial is needed to explore if a CPPopt management results in better functional outcomes.

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“…La corrélation entre la PAM et l'amplitude de l'onde de PIC (Pax) semble être plus robuste pour l'analyse de l'autorégu-lation. L'évaluation est plus fiable pour les PIC basses et permet de détecter les patients avec un mauvais pronostic, même pour des PIC inférieures à 15 mmHg [64].…”

Section: Monitorage De L'autorégulation Cérébraleunclassified

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et al. 2015

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Continuous Monitoring of Cerebrovascular Reactivity Using Pulse Waveform of Intracranial Pressure

Cited by 98 publications

References 25 publications

Critical thresholds for intracranial pressure vary over time in non-craniectomised traumatic brain injury patients

Critical thresholds for intracranial pressure vary over time in non-craniectomised traumatic brain injury patients

Optimal cerebral perfusion pressure in patients with intracerebral hemorrhage: an observational case series

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