Statistical Cerebrovascular Reactivity Signal Properties after Secondary Decompressive Craniectomy in Traumatic Brain Injury: A CENTER-TBI Pilot Analysis

Zeiler, Frederick A.; Aries, Marcel; Cabeleira, Manuel; Essen, Thomas A. van; Stocchetti, Nino; Menon, David; Timofeev, Ivan; Czosnyka, Marek; Smieleweski, Peter; Hutchinson, Peter J.; Ercole, Ari

doi:10.1089/neu.2019.6726

Cited by 35 publications

(29 citation statements)

References 29 publications

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“…There are also some concerns about the validity of PRx and CPPopt after DC. Recent findings in TBI suggest that these measures are still valid after DC [33] and we found no impact on the results including PRx and CPPopt after excluding the patients with DC surgery. In addition, CPPopt might be relatively high in case of cerebral vasospasm and we cannot exclude that we did not reach high enough CPP values that fully explored the upper limit of the CPPopt curve.…”

Section: Methodsological Strengths and Limitationscontrasting

confidence: 53%

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

et al. 2021

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Background High intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome. Methods In this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008–2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP–CPPopt) < − 10 mm Hg (%). Results Of the 242 patients, 63 (26%) had favorable (GOS-E 5–8) and 179 (74%) had unfavorable (GOS-E 1–4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5–10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups. Conclusions Avoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.

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Section: Methodsological Strengths and Limitationscontrasting

confidence: 53%

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

et al. 2021

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“…Time series modeling and analysis have been proven to be very useful for continuous datasets assessing cerebrovascular reactivity. [20][21][22][23] The dependence of (patho-) physiological variables to each other is not always instantaneous, and often the response occurs after a certain lapse of time (lag). A time-series lagged correlation analysis is therefore well suited to study large datasets from patients in the intensive care unit and identify delayed correlations between two physiological variables.…”

Section: Discussionmentioning

confidence: 99%

Effects of Norepinephrine, Propofol, and Hemoglobin Concentration on Dynamic Measurements of Cerebrovascular Reactivity in Acute Brain Injury

Klein

Fieuws

Meyfroidt

et al. 2021

Journal of Neurotrauma

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Effects of treatment-associated variables on cerebrovascular autoregulation (CA) in acute brain injury patients remain unclear. As deficient CA is associated with worse outcomes and ideas about CA-steered management are emerging, this question is relevant. We investigated effects of norepinephrine and propofol infusion rates and hemoglobin concentration on dynamic measurements of cerebrovascular reactivity as surrogate for CA. A retrospective analysis of 91 traumatic brain injury (TBI) and 13 stroke patients admitted to the intensive care unit (ICU) of the Leuven University Hospitals was performed. Low-resolution autoregulation index (LAx) and high-frequency pressure reactivity index (PRx) were calculated as measurements of cerebrovascular reactivity. Data was binned into 5-, 15-, and 60-min intervals. Bivariate time-series analysis using lagged cross-correlations were calculated after pre-whitening and differencing. Linear mixed models evaluated effects of age, gender, cardiovascular risk, brain comorbidity, Glasgow Coma Scale (GCS), pupil reactivity, and type of injury. Median dose of norepinephrine, propofol and hemoglobin concentration was 7.8 μg/kg/h (Q1 3.6-Q3 13.8), 3 mg/kg/h (Q1 1.9-Q3 4.3), and 9.2 gꞏdL −1 (Q1 8.2-Q3 10.5), respectively. Mean crosscorrelations for 24 lags were close to zero and not significant for all variables. No significant differences as function of age, gender, cardiovascular risk, brain comorbidity, GCS, pupil reactivity, and type of injury were found. Dynamic intracranial pressure-based measurements of cerebrovascular reactivity in acute brain injured patients are not affected by gradually adjusted norepinephrine or propofol infusion rates or slow changes in hemoglobin concentration within the typical ranges during ICU admission. Future trials on cerebrovascular reactivity-steered management and treatment of CA impairment may not have to take these variables into account.

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“…In the analysis, the 53 patients in our cohort who underwent DC were included. Including these patients might be regarded a limitation, particularly when previous studies have been inconsistent in whether PRx is affected or not [ 28 , 29 ]. However, it is biologically plausible that ICP elevations are harmful to the brain per se, no matter whether DC has been performed or not.…”

Section: Discussionmentioning

confidence: 99%

Impact of duration and magnitude of raised intracranial pressure on outcome after severe traumatic brain injury: A CENTER-TBI high-resolution group study

et al. 2020

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Magnitude of intracranial pressure (ICP) elevations and their duration have been associated with worse outcomes in patients with traumatic brain injuries (TBI), however published thresholds for injury vary and uncertainty about these levels has received relatively little attention. In this study, we have analyzed high-resolution ICP monitoring data in 227 adult patients in the CENTER-TBI dataset. Our aim was to identify thresholds of ICP intensity and duration associated with worse outcome, and to evaluate the uncertainty in any such thresholds. We present ICP intensity and duration plots to visualize the relationship between ICP events and outcome. We also introduced a novel bootstrap technique to evaluate uncertainty of the equipoise line. We found that an intensity threshold of 18 ± 4 mmHg (2 standard deviations) was associated with worse outcomes in this cohort. In contrast, the uncertainty in what duration is associated with harm was larger, and safe durations were found to be population dependent. The pressure and time dose (PTD) was also calculated as area under the curve above thresholds of ICP. A relationship between PTD and mortality could be established, as well as for unfavourable outcome. This relationship remained valid for mortality but not unfavourable outcome after adjusting for IMPACT core variables and maximum therapy intensity level. Importantly, during periods of impaired autoregulation (defined as pressure reactivity index (PRx)>0.3) ICP events were associated with worse outcomes for nearly all durations and ICP levels in this cohort and there was a stronger relationship between outcome and PTD. Whilst caution should be exercised in ascribing causation in observational analyses, these results suggest intracranial hypertension is poorly tolerated in the presence of impaired autoregulation. ICP level guidelines may need to be revised in the future taking into account cerebrovascular autoregulation status considered jointly with ICP levels.

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Statistical Cerebrovascular Reactivity Signal Properties after Secondary Decompressive Craniectomy in Traumatic Brain Injury: A CENTER-TBI Pilot Analysis

Cited by 35 publications

References 29 publications

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

Effects of Norepinephrine, Propofol, and Hemoglobin Concentration on Dynamic Measurements of Cerebrovascular Reactivity in Acute Brain Injury

Impact of duration and magnitude of raised intracranial pressure on outcome after severe traumatic brain injury: A CENTER-TBI high-resolution group study

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