Serial Measurement of Static and Dynamic Cerebrovascular Autoregulation After Brain Injury

Schramm, Patrick; Klein, Klaus Ulrich; Pape, Monika; Berres, Manfred; Werner, Christian; Kochs, Eberhard; Engelhard, Kristin

doi:10.1097/ana.0b013e3181f35854

Cited by 28 publications

(26 citation statements)

References 22 publications

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“…Explanations of this temporal evolution are, however, difficult; in contrast to the scant studies on the time course of ICP after injury, this is the only study (to our knowledge) to assess continuous cerebral vascular reactivity in relation to time from injury. In contrast to our findings, investigations intermittently assessing pressure autoregulation using transcranial Doppler have found impaired pressure autoregulation in the first 4–5 days postinjury before a gradual return towards normal values [42–45]. Cerebrovascular reactivity can be seen as a proxy variable of various neuropathophysiological processes and interventions that can modulate it.…”

Section: Discussioncontrasting

confidence: 99%

Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study

et al. 2017

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BackgroundBoth intracranial pressure (ICP) and the cerebrovascular pressure reactivity represent the dysregulation of pathways directly involved in traumatic brain injury (TBI) pathogenesis and have been used to inform clinical management. However, how these parameters evolve over time following injury and whether this evolution has any prognostic importance have not been studied.Methods and findingsWe analysed the temporal profile of ICP and pressure reactivity index (PRx), examined their relation to TBI-specific mortality, and determined if the prognostic relevance of these parameters was affected by their temporal profile using mixed models for repeated measures of ICP and PRx for the first 240 hours from the time of injury. A total of 601 adults with TBI, admitted between September 2002 to January 2016, and with high-resolution continuous monitoring from a single centre, were studied. At 6 months postinjury, 133 (19%) patients had a fatal outcome; of those, 88 (78%) died from nonsurvivable TBI or brain death. The difference in mean ICP between those with a fatal outcome and functional survivors was only significant for the first 168 hours after injury (all p < 0.05). For PRx, those patients with a fatal outcome also had a higher (more impaired) PRx throughout the first 120 hours after injury (all p < 0.05). The separation of ICP and PRx was greatest in the first 72 hours after injury. Mixed models demonstrated that the explanatory power of the PRx decreases over time; therefore, the prognostic weight assigned to PRx should similarly decrease. However, the ability of ICP to predict a fatal outcome remained relatively stable over time. As control of ICP is the central purpose of TBI management, it is likely that some of the information that is reflected in the natural history of ICP changes is no longer apparent because of therapeutic intervention.ConclusionsWe demonstrated the temporal evolution of ICP and PRx and their relationship with fatal outcome, indicating a potential early prognostic and therapeutic window. The combination of dynamic monitoring variables and their time profile improved prediction of outcome. Therefore, time-driven dynamic modelling of outcome in patients with severe TBI may allow for more accurate and clinically useful prediction models. Further research is needed to confirm and expand on these findings.

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Section: Discussioncontrasting

confidence: 99%

Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study

et al. 2017

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“…The index of AR Mx was measured on a daily basis during the first 4 days after the onset of sepsis, showing an increased index Mx and, thereby, a disturbed AR during the first 2 days of sepsis followed by a recovery of AR during the next two days. This time course with initial impaired AR followed by a recovery was also observed in patients with intracranial lesions [19]. The question of whether the disturbance of AR is a clinical sign of critically ill patients in general, or a typical problem of septic patients, cannot be answered by the present study.…”

Section: Discussionmentioning

confidence: 51%

Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsis-associated delirium

et al. 2012

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IntroductionSepsis-associated delirium (SAD) increases morbidity in septic patients and, therefore, factors contributing to SAD should be further characterized. One possible mechanism might be the impairment of cerebrovascular autoregulation (AR) by sepsis, leading to cerebral hypo- or hyperperfusion in these haemodynamically unstable patients. Therefore, the present study investigates the relationship between the incidence of SAD and the status of AR during sepsis.MethodsCerebral blood flow velocity was measured using transcranial Doppler sonography and was correlated with the invasive arterial blood pressure curve to calculate the index of AR Mx (Mx>0.3 indicates impaired AR). Mx was measured daily during the first 4 days of sepsis. Diagnosis of a SAD was performed using the confusion assessment method for ICU (CAM-ICU) and, furthermore the predominant brain electrical activity in electroencephalogram (EEG) both at day 4 after reduction of sedation to RASS >-2.Results30 critically ill adult patients with severe sepsis or septic shock (APACHE II 32 ± 6) were included. AR was impaired at day 1 in 60%, day 2 in 59%, day 3 in 41% and day 4 in 46% of patients; SAD detected by CAM-ICU was present in 76 % of patients. Impaired AR at day 1 was associated with the incidence of SAD at day 4 (p = 0.035).ConclusionsAR is impaired in the great majority of patients with severe sepsis during the first two days. Impaired AR is associated with SAD, suggesting that dysfunction of AR is one of the trigger mechanisms contributing to the development of SAD.Trial registrationclinicalTrials.gov ID NCT01029080

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“…Within 7 days of serial measurements, Schramm et al demonstrated that both dynamic and static CA were impaired after severe brain injury and that ICH patients with a nadir on day 4 subsequently experienced an incomplete recovery over time. 21 Yet, with a study length of 1 month, we found a prolonged impairment of dCA for at least 10 to 12 days post ictus. Moreover, PD and RoRc values indicated the worst autoregulation at that time point.…”

Section: March 2016mentioning

confidence: 95%

Temporal Course of Dynamic Cerebral Autoregulation in Patients With Intracerebral Hemorrhage

Hanson

Guo

Jia³

et al. 2016

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Reports of dCA in patients with ICH group are scarce, yet diverse. In a case-control study, a higher gain was observed within 3 days of ICH onset when compared with the healthy controls, indicating a less effective dCA during the acute stage. 7 In a recent study, researchers obtained serial measurements and stated that a higher bilateral gain could last 5 days Background and Purpose-Cerebral autoregulation is crucial in patients with intracerebral hemorrhage. Dynamic cerebral autoregulation is probably altered in acute intracerebral hemorrhage; however, the temporal course of dynamic cerebral autoregulation and its correlation with clinical factors and outcomes are poorly understood. Methods-Forty-three acute supratentorial intracerebral hemorrhage patients (53.7±10.0 years old, 30 men) were enrolled for serial measurements performed on days 1 to 2, 4 to 6, 10 to 12, and 30 days after ictus. Noninvasive continuous cerebral blood flow velocity and arterial blood pressure were recorded simultaneously using transcranial Doppler and a servocontrolled plethysmograph, respectively. Transfer function analysis was used to derive the autoregulatory parameters, including phase difference (PD), gain, and the rate of recovery of cerebral blood flow velocity. Results were compared with healthy controls and correlated with clinical factors and the 90-day outcome. Results-PD did not differ between affected and unaffected hemispheres over time. A significant lower PD (indicating dynamic cerebral autoregulation impaired) was found in bilateral hemispheres on days 1 to 2, 4 to 6, and 10 to 12, followed by later recovery on day 30. Lower bilateral PD on days 1 to 2 was associated with poorer Glasgow Coma Scale score at that time. Lower affected-side PD on days 4 to 6 was an independent predictive value for a poorer modified Rankin Scale at 90 days. Conclusions-In patients with supratentorial intracerebral hemorrhage, dynamic cerebral autoregulation is bilaterally impaired lasting at least 10 to 12 days and recovers within a month. Individual PD value is associated with clinical status at acute stage and affected-side PD on days 4 to 6 can be an independent predictor for clinical outcome. after ictus, whereas a higher gain value was not associated with any clinical factors or outcome. 14 Serial index Mx (reflecting both static and dynamic CA) was also derived within 5 days after ICH onset. Although it was not generally impaired on the first day, a secondary decline between days 3 and 5 could possibly occur mainly on the affected side, and this may be associated with poorer clinical status and outcomes.15 Yet, the above studies all garnered attention toward the early stage after ICH, while ignoring the subacute and recovery stages. This left unresolved whether, when, and to what extent could the altered dCA be restored.Thus, in the present study, we sought to (1) investigate the time course of dCA in ICH patients with serial follow-ups, including 1 to 2 days after ictus and 3 additional time points within a month, and (2) explore th...

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Serial Measurement of Static and Dynamic Cerebrovascular Autoregulation After Brain Injury

Abstract: Daily measured dAR and sAR were impaired after brain injury with a nadir on day 4 and consecutive incomplete recovery over time.

Cited by 28 publications

References 22 publications

Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study

Temporal profile of intracranial pressure and cerebrovascular reactivity in severe traumatic brain injury and association with fatal outcome: An observational study

Impaired cerebrovascular autoregulation in patients with severe sepsis and sepsis-associated delirium

Temporal Course of Dynamic Cerebral Autoregulation in Patients With Intracerebral Hemorrhage

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