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Svedung Wettervik TM, Hånell A, Howells T, Ronne-Engström E, Lewén A, Enblad P. Individualized Autoregulation-Derived Cerebral Perfusion Targets in Aneurysmal Subarachnoid Hemorrhage: A New Therapeutic Avenue? J Intensive Care Med 2024:8850666241252415. [PMID: 38706245 DOI: 10.1177/08850666241252415] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 05/07/2024]
Abstract
Background: Cerebral perfusion pressure (CPP) is an important target in aneurysmal subarachnoid hemorrhage (aSAH), but it does not take into account autoregulatory disturbances. The pressure reactivity index (PRx) and the CPP with the optimal PRx (CPPopt) are new variables that may capture these pathomechanisms. In this study, we investigated the effect on the outcome of certain combinations of CPP or ΔCPPopt (actual CPP-CPPopt) with the concurrent autoregulatory status (PRx) after aSAH. Methods: This observational study included 432 aSAH patients, treated in the neurointensive care unit, at Uppsala University Hospital, Sweden. Functional outcome (GOS-E) was assessed 1-year postictus. Heatmaps of the percentage of good monitoring time (%GMT) of PRx/CPP and PRx/ΔCPPopt combinations in relation to GOS-E were created to visualize the association between these variables and outcome. Results: In the heatmap of the %GMT of PRx/CPP, the combination of lower CPP with higher PRx values was more strongly associated with lower GOS-E. The tolerance for lower CPP values increased with lower PRx values until a threshold of -0.50. However, for decreasing PRx below -0.50, there was a gradual reduction in the tolerance for lower CPP. In the heatmap of the %GMT of PRx/ΔCPPopt, the combination of negative ΔCPPopt with higher PRx values was strongly associated with lower GOS-E. In particular, negative ΔCPPopt together with PRx above +0.50 correlated with worse outcomes. In addition, there was a transition toward an unfavorable outcome when PRx went below -0.50, particularly if ΔCPPopt was negative. Conclusions: The PRx levels influenced the association between CPP/ΔCPPopt and outcome. Thus, this variable could be used to individualize a safe CPP-/ΔCPPopt-range.
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Affiliation(s)
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | | | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, Uppsala, Sweden
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Svedung Wettervik T, Howells T, Hånell A, Lewén A, Enblad P. The Optimal pressure reactivity index range is disease-specific: A comparison between aneurysmal subarachnoid hemorrhage and traumatic brain injury. J Clin Monit Comput 2024:10.1007/s10877-024-01168-9. [PMID: 38702589 DOI: 10.1007/s10877-024-01168-9] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/28/2024] [Accepted: 04/22/2024] [Indexed: 05/06/2024]
Abstract
PURPOSE Impaired cerebral pressure autoregulation is common and detrimental after acute brain injuries. Based on the prevalence of delayed cerebral ischemia in aneurysmal subarachnoid hemorrhage (aSAH) patients compared to traumatic brain injury (TBI), we hypothesized that the type of autoregulatory disturbance and the optimal PRx range may differ between these two conditions. The aim of this study was to determine the optimal PRx ranges in relation to functional outcome following aSAH and TBI, respectively. METHODS In this observational study, 487 aSAH patients and 413 TBI patients, treated in the neurointensive care, Uppsala, Sweden, between 2008 and 2018, were included. The percentage of good monitoring time (%GMT) of PRx was calculated within 8 intervals covering the range from -1.0 to + 1.0, and analyzed in relation to favorable outcome (GOS-E 5 to 8). RESULTS In multiple logistic regressions, a higher %GMTs of PRx in the intervals -1.0 to -0.5 and + 0.75 to + 1.0 were independently associated with a lower rate of favorable outcome in the aSAH cohort. In a similar analysis in the TBI cohort, only positive PRx in the interval + 0.75 to + 1.0 was independently associated with a lower rate of favorable outcome. CONCLUSION Extreme PRx values in both directions were unfavorable in aSAH, possibly as high PRx could indicate proximal vasospasm with exhausted distal vasodilatory reserve, while very negative PRx could reflect myogenic hyperreactivity with suppressed cerebral blood flow. Only elevated PRx was unfavorable in TBI, possibly as pressure passive vessels may be a more predominant pathomechanism in this disease.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Svedung Wettervik T, Hånell A, Lewén A, Enblad P. Should Patients with Traumatic Brain Injury with Significant Contusions be Treated with Different Neurointensive Care Targets? Neurocrit Care 2024:10.1007/s12028-024-01954-y. [PMID: 38506969 DOI: 10.1007/s12028-024-01954-y] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2023] [Accepted: 02/01/2024] [Indexed: 03/22/2024]
Abstract
BACKGROUND Patients with traumatic brain injury (TBI) with large contusions make up a specific TBI subtype. Because of the risk of brain edema worsening, elevated cerebral perfusion pressure (CPP) may be particularly dangerous. The pressure reactivity index (PRx) and optimal cerebral perfusion pressure (CPPopt) are new promising perfusion targets based on cerebral autoregulation, but they reflect the global brain state and may be less valid in patients with predominant focal lesions. In this study, we aimed to investigate if patients with TBI with significant contusions exhibited a different association between PRx, CPP, and CPPopt in relation to functional outcome compared to those with small/no contusions. METHODS This observational study included 385 patients with moderate to severe TBI treated at a neurointensive care unit in Uppsala, Sweden. The patients were classified into two groups: (1) significant contusions (> 10 mL) and (2) small/no contusions (but with extra-axial or diffuse injuries). The percentage of good monitoring time (%GMT) with intracranial pressure > 20 mm Hg; PRx > 0.30; CPP < 60 mm Hg, within 60-70 mm Hg, or > 70 mm Hg; and ΔCPPopt less than - 5 mm Hg, ± 5 mm Hg, or > 5 mm Hg was calculated. Outcome (Glasgow Outcome Scale-Extended) was assessed after 6 months. RESULTS Among the 120 (31%) patients with significant contusions, a lower %GMT with CPP between 60 and 70 mm Hg was independently associated with unfavorable outcome. The %GMTs with PRx and ΔCPPopt ± 5 mm Hg were not independently associated with outcome. Among the 265 (69%) patients with small/no contusions, a higher %GMT of PRx > 0.30 and a lower %GMT of ΔCPPopt ± 5 mm Hg were independently associated with unfavorable outcome. CONCLUSIONS In patients with TBI with significant contusions, CPP within 60-70 mm Hg may improve outcome. PRx and CPPopt, which reflect global cerebral pressure autoregulation, may be useful in patients with TBI without significant focal brain lesions but seem less valid for those with large contusions. However, this was an observational, hypothesis-generating study; our findings need to be validated in prospective studies before translating them into clinical practice.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Svedung Wettervik T, Velle F, Hånell A, Howells T, Nilsson P, Lewén A, Enblad P. ICP, PRx, CPP, and ∆CPPopt in pediatric traumatic brain injury: the combined effect of insult intensity and duration on outcome. Childs Nerv Syst 2023; 39:2459-2466. [PMID: 37270434 PMCID: PMC10432317 DOI: 10.1007/s00381-023-05982-5] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/31/2023] [Accepted: 04/30/2023] [Indexed: 06/05/2023]
Abstract
PURPOSE The aim was to investigate the combined effect of insult intensity and duration, regarding intracranial pressure (ICP), pressure reactivity index (PRx), cerebral perfusion pressure (CPP), and optimal CPP (CPPopt), on clinical outcome in pediatric traumatic brain injury (TBI). METHOD This observational study included 61 pediatric patients with severe TBI, treated at the Uppsala University Hospital, between 2007 and 2018, with at least 12 h of ICP data the first 10 days post-injury. ICP, PRx, CPP, and ∆CPPopt (actual CPP-CPPopt) insults were visualized as 2-dimensional plots to illustrate the combined effect of insult intensity and duration on neurological recovery. RESULTS This cohort was mostly adolescent pediatric TBI patients with a median age at 15 (interquartile range 12-16) years. For ICP, brief episodes (minutes) above 25 mmHg and slightly longer episodes (20 min) of ICP 20-25 mmHg correlated with unfavorable outcome. For PRx, brief episodes above 0.25 as well as slightly lower values (around 0) for longer periods of time (30 min) were associated with unfavorable outcome. For CPP, there was a transition from favorable to unfavorable outcome for CPP below 50 mmHg. There was no association between high CPP and outcome. For ∆CPPopt, there was a transition from favorable to unfavorable outcome when ∆CPPopt went below -10 mmHg. No association was found for positive ∆CPPopt values and outcome. CONCLUSIONS This visualization method illustrated the combined effect of insult intensity and duration in relation to outcome in severe pediatric TBI, supporting previous notions to avoid high ICP and low CPP for longer episodes of time. In addition, higher PRx for longer episodes of time and CPP below CPPopt more than -10 mmHg were associated with worse outcome, indicating a potential role for autoregulatory-oriented management in pediatric TBI.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Fartein Velle
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Timothy Howells
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Medical Sciences, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
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Svedung Wettervik T, Hånell A, Ronne-Engström E, Lewén A, Enblad P. Temperature Changes in Poor-Grade Aneurysmal Subarachnoid Hemorrhage: Relation to Injury Pattern, Intracranial Pressure Dynamics, Cerebral Energy Metabolism, and Clinical Outcome. Neurocrit Care 2023; 39:145-154. [PMID: 36922474 PMCID: PMC10499919 DOI: 10.1007/s12028-023-01699-0] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2022] [Accepted: 02/13/2023] [Indexed: 03/17/2023]
Abstract
BACKGROUND The aim was to study the course of body temperature in the acute phase of poor-grade aneurysmal subarachnoid hemorrhage (aSAH) in relation to the primary brain injury, cerebral physiology, and clinical outcome. METHODS In this observational study, 166 patients with aSAH treated at the neurosurgery department at Uppsala University Hospital in Sweden between 2008 and2018 with temperature, intracranial pressure (ICP), and microdialysis (MD) monitoring were included. The first 10 days were divided into the early phase (days 1-3) and the vasospasm phase (days 4-10). RESULTS Normothermia (temperature = 36-38 °C) was most prevalent in the early phase. A lower mean temperature at this stage was univariately associated with a worse primary brain injury, with higher Fisher grade and higher MD glycerol concentration, as well as a worse neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the early phase. There was a transition toward an increased burden of hyperthermia (temperature > 38 °C) in the vasospasm phase. This was associated with concurrent infections but not with neurological or radiological injury severity at admission. Elevated temperature was associated with higher MD pyruvate concentration, lower rate of an MD pattern indicative of ischemia, and higher rate of poor neurological recovery at 1 year. There was otherwise no association between temperature and cerebral physiological variables in the vasospasm phase. The associations between temperature and clinical outcome did not hold true in multiple logistic regression analyses. CONCLUSIONS Spontaneously low temperature in the early phase reflected a worse primary brain injury and indicated a worse outcome prognosis. Hyperthermia was common in the vasospasm phase and was more related to infections than primary injury severity but also with a more favorable energy metabolic pattern with better substrate supply, possibly related to hyperemia.
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Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
| | - Anders Hånell
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden
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Svedung Wettervik T, Hånell A, Howells T, Engström ER, Lewén A, Enblad P. Autoregulatory Cerebral Perfusion Pressure Insults in Traumatic Brain Injury and Aneurysmal Subarachnoid Hemorrhage: The Role of Insult Intensity and Duration on Clinical Outcome. J Neurosurg Anesthesiol 2023:00008506-990000000-00064. [PMID: 37212723 DOI: 10.1097/ana.0000000000000922] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/29/2022] [Accepted: 04/10/2023] [Indexed: 05/23/2023]
Abstract
BACKGROUND This single-center, retrospective study investigated the outcome effect of the combined intensity and duration of differences between actual cerebral perfusion pressure (CPP) and optimal cerebral perfusion pressure (CPPopt), and also for absolute CPP, in patients with traumatic brain injury (TBI) and aneurysmal subarachnoid hemorrhage (aSAH). METHODS A total of 378 TBI and 432 aSAH patients treated in a neurointensive care unit between 2008 and 2018 with at least 24 hours of CPPopt data during the first 10 days following injury, and with 6-month (TBI) or 12-month (aSAH) extended Glasgow Outcome Scale (GOS-E) scores, were included in the study. ∆CPPopt-insults (∆CPPopt=actual CPP-CPPopt) and CPP-insults were visualized as 2-dimensional plots to highlight the combined effect of insult intensity (mm Hg) and duration (min) on patient outcome. RESULTS In TBI patients, a zone of ∆CPPopt ± 10 mm Hg was associated with more favorable outcome, with transitions towards unfavorable outcome above and below this zone. CPP in the range of 60 to 80 mm Hg was associated with higher GOS-E, whereas CPP outside this range was associated with lower GOS-E. In aSAH patients, there was no clear transition from higher to lower GOS-E for ∆CPPopt-insults; however, there was a transition from favorable to unfavorable outcome when CPP was <80 mm Hg. CONCLUSIONS TBI patients with CPP close to CPPopt exhibited better clinical outcomes, and absolute CPP within the 60 to 80 mm Hg range was also associated with favorable outcome. In aSAH patients, there was no clear transition for ∆CPPopt-insults in relation to outcome, whereas generally high absolute CPP values were associated overall with favorable recovery.
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Intracranial Pressure Variability: A New Potential Metric of Cerebral Ischemia and Energy Metabolic Dysfunction in Aneurysmal Subarachnoid Hemorrhage? J Neurosurg Anesthesiol 2023; 35:208-214. [PMID: 36877175 DOI: 10.1097/ana.0000000000000816] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/01/2021] [Accepted: 09/08/2021] [Indexed: 11/25/2022]
Abstract
BACKGROUND It was recently reported that lower intracranial pressure variability (ICPV) is associated with delayed ischemic neurological deficits and unfavorable outcomes in patients with aneurysmal subarachnoid hemorrhage (aSAH). In this study, we aimed to determine whether lower ICPV also correlated with worse cerebral energy metabolism after aSAH. METHODS A total of 75 aSAH patients treated in the neurointensive care unit at Uppsala University Hospital, Sweden between 2008 and 2018 and with both intracranial pressure and cerebral microdialysis (MD) monitoring during the first 10 days after ictus were included in this retrospective study. ICPV was calculated with a bandpass filter limited to intracranial pressure slow waves with a wavelength of 55 to 15 seconds. Cerebral energy metabolites were measured hourly with MD. The monitoring period was divided into 3 phases; early (days 1 to 3), early vasospasm (days 4 to 6.5), and late vasospasm (days 6.5 to 10). RESULTS Lower ICPV was associated with lower MD-glucose in the late vasospasm phase, lower MD-pyruvate in the early vasospasm phases, and higher MD-lactate-pyruvate ratio (LPR) in the early and late vasospasm phases. Lower ICPV was associated with poor cerebral substrate supply (LPR >25 and pyruvate <120 µM) rather than mitochondrial failure (LPR >25 and pyruvate >120 µM). There was no association between ICPV and delayed ischemic neurological deficit, but lower ICPV in both vasospasm phases correlated with unfavorable outcomes. CONCLUSION Lower ICPV was associated with an increased risk for disturbed cerebral energy metabolism and worse clinical outcomes in aSAH patients, possibly explained by a vasospasm-related decrease in cerebral blood volume dynamics and cerebral ischemia.
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Higher intracranial pressure variability is associated with lower cerebrovascular resistance in aneurysmal subarachnoid hemorrhage. J Clin Monit Comput 2023; 37:319-326. [PMID: 35842879 PMCID: PMC9852113 DOI: 10.1007/s10877-022-00894-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 07/04/2022] [Indexed: 01/24/2023]
Abstract
Higher intracranial pressure variability (ICPV) has been associated with a more favorable cerebral energy metabolism, lower rate of delayed ischemic neurologic deficits, and more favorable outcome in aneurysmal subarachnoid hemorrhage (aSAH). We have hypothesized that higher ICPV partly reflects more compliant and active cerebral vessels. In this study, the aim was to further test this by investigating if higher ICPV was associated with lower cerebrovascular resistance (CVR) and higher cerebral blood flow (CBF) after aSAH. In this observational study, 147 aSAH patients were included, all of whom had been treated in the Neurointensive Care (NIC) Unit, Uppsala, Sweden, 2012-2020. They were required to have had ICP monitoring and at least one xenon-enhanced computed tomography (Xe-CT) scan to study cortical CBF within the first 2 weeks post-ictus. CVR was defined as the cerebral perfusion pressure in association with the Xe-CT scan divided by the concurrent CBF. ICPV was defined over three intervals: subminute (ICPV-1m), 30-min (ICPV-30m), and 4 h (ICPV-4h). The first 14 days were divided into early (days 1-3) and vasospasm phase (days 4-14). In the vasospasm phase, but not in the early phase, higher ICPV-4h (β = - 0.19, p < 0.05) was independently associated with a lower CVR in a multiple linear regression analysis and with a higher global cortical CBF (r = 0.19, p < 0.05) in a univariate analysis. ICPV-1m and ICPV-30m were not associated with CVR or CBF in any phase. This study corroborates the hypothesis that higher ICPV, at least in the 4-h interval, is favorable and may reflect more compliant and possibly more active cerebral vessels.
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Intracranial pressure- and cerebral perfusion pressure threshold-insults in relation to cerebral energy metabolism in aneurysmal subarachnoid hemorrhage. Acta Neurochir (Wien) 2022; 164:1001-1014. [PMID: 35233663 PMCID: PMC8967735 DOI: 10.1007/s00701-022-05169-y] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/29/2021] [Accepted: 02/22/2022] [Indexed: 11/15/2022]
Abstract
Background The aim was to investigate the association between intracranial pressure (ICP)- and cerebral perfusion pressure (CPP) threshold-insults in relation to cerebral energy metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). Methods In this retrospective study, 75 aSAH patients treated in the neurointensive care unit, Uppsala, Sweden, 2008–2018, with ICP and cerebral microdialysis (MD) monitoring were included. The first 10 days were divided into early (day 1–3), early vasospasm (day 4–6.5), and late vasospasm phase (day 6.5–10). The monitoring time (%) of ICP insults (> 20 mmHg and > 25 mmHg), CPP insults (< 60 mmHg, < 70 mmHg, < 80 mmHg, and < 90 mmHg), and autoregulatory CPP optimum (CPPopt) insults (∆CPPopt = CPP-CPPopt < − 10 mmHg, ∆CPPopt > 10 mmHg, and within the optimal interval ∆CPPopt ± 10 mmHg) were calculated in each phase. Results Higher percent of ICP above the 20 mmHg and 25 mmHg thresholds correlated with lower MD-glucose and increased MD-lactate-pyruvate ratio (LPR), particularly in the vasospasm phases. Higher percentage of CPP below all four thresholds (60/70/80//90 mmHg) also correlated with a MD pattern of poor cerebral substrate supply (MD-LPR > 40 and MD-pyruvate < 120 µM) in the vasospasm phase and higher burden of CPP below 60 mmHg was independently associated with higher MD-LPR in the late vasospasm phase. Higher percentage of CPP deviation from CPPopt did not correlate with worse cerebral energy metabolism. Higher burden of CPP-insults below all fixed thresholds in both vasospasm phases were associated with worse clinical outcome. The percentage of ICP-insults and CPP close to CPPopt were not associated with clinical outcome. Conclusions Keeping ICP below 20 mmHg and CPP at least above 60 mmHg may improve cerebral energy metabolism and clinical outcome. Supplementary Information The online version contains supplementary material available at 10.1007/s00701-022-05169-y.
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Lidington D, Wan H, Bolz SS. Cerebral Autoregulation in Subarachnoid Hemorrhage. Front Neurol 2021; 12:688362. [PMID: 34367053 PMCID: PMC8342764 DOI: 10.3389/fneur.2021.688362] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/30/2021] [Accepted: 06/25/2021] [Indexed: 12/28/2022] Open
Abstract
Subarachnoid hemorrhage (SAH) is a devastating stroke subtype with a high rate of mortality and morbidity. The poor clinical outcome can be attributed to the biphasic course of the disease: even if the patient survives the initial bleeding emergency, delayed cerebral ischemia (DCI) frequently follows within 2 weeks time and levies additional serious brain injury. Current therapeutic interventions do not specifically target the microvascular dysfunction underlying the ischemic event and as a consequence, provide only modest improvement in clinical outcome. SAH perturbs an extensive number of microvascular processes, including the “automated” control of cerebral perfusion, termed “cerebral autoregulation.” Recent evidence suggests that disrupted cerebral autoregulation is an important aspect of SAH-induced brain injury. This review presents the key clinical aspects of cerebral autoregulation and its disruption in SAH: it provides a mechanistic overview of cerebral autoregulation, describes current clinical methods for measuring autoregulation in SAH patients and reviews current and emerging therapeutic options for SAH patients. Recent advancements should fuel optimism that microvascular dysfunction and cerebral autoregulation can be rectified in SAH patients.
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Affiliation(s)
- Darcy Lidington
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Hoyee Wan
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada
| | - Steffen-Sebastian Bolz
- Department of Physiology, University of Toronto, Toronto, ON, Canada.,Toronto Centre for Microvascular Medicine at the Ted Rogers Centre for Heart Research Translational Biology and Engineering Program, University of Toronto, Toronto, ON, Canada.,Heart & Stroke/Richard Lewar Centre of Excellence for Cardiovascular Research, University of Toronto, Toronto, ON, Canada
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Svedung Wettervik T, Howells T, Lewén A, Ronne-Engström E, Enblad P. Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome. Neurocrit Care 2021; 34:390-402. [PMID: 33420669 PMCID: PMC8128752 DOI: 10.1007/s12028-020-01162-4] [Citation(s) in RCA: 19] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2020] [Accepted: 11/18/2020] [Indexed: 12/23/2022]
Abstract
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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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, 751 85, Uppsala, Sweden
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Svedung Wettervik T, Howells T, Hånell A, Ronne-Engström E, Lewén A, Enblad P. Low intracranial pressure variability is associated with delayed cerebral ischemia and unfavorable outcome in aneurysmal subarachnoid hemorrhage. J Clin Monit Comput 2021; 36:569-578. [PMID: 33728586 PMCID: PMC9123038 DOI: 10.1007/s10877-021-00688-y] [Citation(s) in RCA: 4] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/10/2020] [Accepted: 03/04/2021] [Indexed: 11/30/2022]
Abstract
Purpose High intracranial pressure variability (ICPV) is associated with favorable outcome in traumatic brain injury, by mechanisms likely involving better cerebral blood flow regulation. However, less is known about ICPV in aneurysmal subarachnoid hemorrhage (aSAH). In this study, we investigated the explanatory variables for ICPV in aSAH and its association with delayed cerebral ischemia (DCI) and clinical outcome. Methods
In this retrospective study, 242 aSAH patients, treated at the neurointensive care, Uppsala, Sweden, 2008–2018, with ICP monitoring the first ten days post-ictus were included. ICPV was evaluated on three time scales: (1) ICPV-1 m—ICP slow wave amplitude of wavelengths between 55 and 15 s, (2) ICPV-30 m—the deviation from the mean ICP averaged over 30 min, and (3) ICPV-4 h—the deviation from the mean ICP averaged over 4 h. The ICPV measures were analyzed in the early phase (day 1–3), in the early vasospasm phase (day 4–6.5), and the late vasospasm phase (day 6.5–10). Results High ICPV was associated with younger age, reduced intracranial pressure/volume reserve (high RAP), and high blood pressure variability in multiple linear regression analyses for all ICPV measures. DCI was associated with reduced ICPV in both vasospasm phases. High ICPV-1 m in the post-ictal early phase and the early vasospasm phase predicted favorable outcome in multiple logistic regressions, whereas ICPV-30 m and ICPV-4 h in the late vasospasm phase had a similar association. Conclusions Higher ICPV may reflect more optimal cerebral vessel activity, as reduced values are associated with an increased risk of DCI and unfavorable outcome after aSAH.
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Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden.
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Hånell
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Elisabeth Ronne-Engström
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, SE-751 85, Uppsala, Sweden
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Kramer AH. Critical ICP in Subarachnoid Hemorrhage: How High and How Long? Neurocrit Care 2021; 34:714-716. [PMID: 33655454 DOI: 10.1007/s12028-021-01205-4] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2021] [Accepted: 02/03/2021] [Indexed: 11/25/2022]
Affiliation(s)
- Andreas H Kramer
- Departments of Critical Care Medicine and Clinical Neurosciences, University of Calgary, ICU Administration, 3132 Hospital Drive NW, Calgary, AB , T2N 5A1, Canada.
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14
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Teichmann D, Lynch JC, Heldt T. Distortion of the Intracranial Pressure Waveform by Extraventricular Drainage System. IEEE Trans Biomed Eng 2020; 68:1646-1657. [PMID: 33156777 DOI: 10.1109/tbme.2020.3036283] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Abstract
OBJECTIVE To investigate whether intracranial pressure (ICP) waveform measurements obtained from extraventricular drainage (EVD) systems are suitable for the calculation of intracranial elastance (ICE) or cerebrovascular pressure autoregulation (PAR) indices. METHODS The transfer characteristic of an EVD system is investigated by its step and frequency responses with focus on the low frequency (LF) range from 0.02 to 0.065 Hz (important in PAR) and the location of the system's first resonance frequency (important for ICE). The effects of opening the distal end of the EVD for drainage of cerebrospinal fluid and the presence of trapped air bubbles are also investigated. RESULTS The EVD system exhibits a first resonant frequency below 4 Hz, resulting in significant distortion of the measured ICP waveform. The frequency response in the LF range only remains flat when the EVD is closed. Opening the drain results in drops in magnitude and phase along the entire frequency range above DC. Air bubbles close to the EVD catheter tip affect the LF range while an air bubble close to the pressure transducer further decreases the first resonant frequency. Tests with actual ICP waveforms confirmed EVD-induced waveform distortions that can lead to erroneous ICE estimation. CONCLUSION EVD-based ICP measurements distort the waveform morphology. PAR indices based on LF information are only valid if the EVD is closed. EVD-based ICE estimation is to be avoided. SIGNIFICANCE ICP waveform analyses to derive information about ICE and PAR should be critically questioned if only EVD derived ICP signals are at hand.
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15
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Intracranial Pressure Dynamics and Cerebral Vasomotor Reactivity in Coronavirus Disease 2019 Patient With Acute Encephalitis. Crit Care Explor 2020; 2:e0197. [PMID: 32885174 PMCID: PMC7434416 DOI: 10.1097/cce.0000000000000197] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/12/2023] Open
Abstract
We describe the intracranial pressure dynamics and cerebral vasomotor reactivity in a coronavirus disease 2019 patient with acute encephalitis treated with cerebrospinal fluid drainage and therapeutic plasma exchange.
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Svedung Wettervik T, Howells T, Enblad P, Lewén A. Temporal Neurophysiological Dynamics in Traumatic Brain Injury: Role of Pressure Reactivity and Optimal Cerebral Perfusion Pressure for Predicting Outcome. J Neurotrauma 2019; 36:1818-1827. [DOI: 10.1089/neu.2018.6157] [Citation(s) in RCA: 32] [Impact Index Per Article: 6.4] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Teodor Svedung Wettervik
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Timothy Howells
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience, Section of Neurosurgery, Uppsala University, Uppsala University Hospital, Uppsala, Sweden
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17
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Wang AYC, Hsieh PC, Chen CC, Chin SC, Wu YM, Chen CT, Chang CH, Wu TWE. Effect of Intracranial Pressure Control on Improvement of Cerebral Perfusion After Acute Subarachnoid Hemorrhage: A Comparative Angiography Study Based on Temporal Changes of Intracranial Pressure and Systemic Pressure. World Neurosurg 2018; 120:e290-e296. [PMID: 30142432 DOI: 10.1016/j.wneu.2018.08.053] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/07/2018] [Revised: 08/07/2018] [Accepted: 08/09/2018] [Indexed: 10/28/2022]
Abstract
OBJECTIVE Increased intracranial pressure (ICP) is a well-known complication after aneurysmal subarachnoid hemorrhage (aSAH). This study focused on the different temporal changes in ICP, mean arterial pressure, and cerebral perfusion pressure at the early stage of aSAH, throughout aneurysm embolization, and their effects on improvement in angiographic perfusion patterns. METHODS Twenty-seven patients with aSAH were evaluated who underwent coiling and cerebrospinal fluid (CSF) drainage. Diagnostic angiography was performed to confirm the presence and location of the vascular lesion. The transit time of the capillary filling phase was defined as a surrogate of cerebral perfusion. Capillary filling transit times were compared before and after CSF drainage. Univariate and multivariate analyses were performed to identify associations between different physical parameters and capillary filling transit times. RESULTS By univariate analysis, average capillary transit time before CSF drainage had a significant correlation with initial ICP (P = 0.0004; R2 = 0.398) but not systemic pressure (mean arterial pressure or cerebral perfusion pressure). Improvement in capillary filling pattern (i.e., a decrease in angiographic capillary transit time after CSF drainage) was seen in patients with high initial ICP and correlated with ICP difference after ventricular drainage (P = 0.0001 and P < 0.0001, respectively). Using multivariate regression analysis, improved control in postprocedural ICP levels significantly correlated with angiographic evidence of improved cerebral perfusion (P = 0.0243). CONCLUSIONS Decreasing ICP by CSF drainage strongly correlated with improved cerebral microcirculation after aSAH. Further development of ICP control protocols that can provide better ICP management of patients with aSAH is warranted.
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Affiliation(s)
- Alvin Yi-Chou Wang
- Department of Neurosurgery, Guangdong Provincial Hospital of Chinese Medicine, Guangzhou, Guangdong, China
| | - Po-Chuan Hsieh
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China.
| | - Ching-Chang Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Shy-Chyi Chin
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Yi-Ming Wu
- Department of Medical Imaging and Intervention, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Chun-Ting Chen
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Chien-Hung Chang
- Department of Neurology, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
| | - Tai-Wei Erich Wu
- Department of Neurosurgery, Chang Gung Memorial Hospital, Linkou, Chang Gung University and Medical College, Taiwan, Republic of China
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18
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Gaasch M, Schiefecker AJ, Kofler M, Beer R, Rass V, Pfausler B, Thomé C, Schmutzhard E, Helbok R. Cerebral Autoregulation in the Prediction of Delayed Cerebral Ischemia and Clinical Outcome in Poor-Grade Aneurysmal Subarachnoid Hemorrhage Patients*. Crit Care Med 2018; 46:774-780. [DOI: 10.1097/ccm.0000000000003016] [Citation(s) in RCA: 35] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Copplestone S, Welbourne J. A narrative review of the clinical application of pressure reactiviy indices in the neurocritical care unit. Br J Neurosurg 2018; 32:4-12. [PMID: 29298527 DOI: 10.1080/02688697.2017.1416063] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/21/2022]
Abstract
Pressure reactivity indices are used in clinical research as a surrogate marker of the ability of the cerebrovasculature to maintain cerebral autoregulation. The use of pressure reactivity indices in patients with neurological injury represents a potential to move away from population-based physiological targets used in guidelines to individualized physiological targets. The aim of this review is to describe the underlying principles and development of pressure reactivity indices, alongside a critique of how they have been used in clinical research, including their limitations. The primary source literature was identified from a database search of PUBMed and OVID online using the search terms "pressure reactivity index" and "pressure reactivity indices". The evidence base regarding pressure reactivity indices currently remains Level III. Pressure reactivity indices rely on the correlation (-1 to +1) between the arterial blood pressure and intracranial pressure, with negative values indicating intact cerebral autoregulation and positive values indicating dysfunctional cerebral autoregulation. Meaningful data is taken from summary measures and trends. The traumatic brain injury population feature most prominently in the literature. There is limited description of the potential confounding factors that may affect pressure reactivity indices, including physiological parameters and therapeutic interventions. Plotting a pressure reactivity index against a cerebral perfusion pressure can indicate an optimal cerebral perfusion pressure to individualise patient care. There is potential to over interpret optimal cerebral perfusion pressure targets when the values of pressure reactivity indices are close to zero. There is an association between pressure reactivity indices and neurological outcomes, however the use of pressure reactivity indices as a prognostication tool is to be challenged. Average values of cerebral perfusion pressure that are not close to averaged values of optimal cerebral perfusion pressure are also associated with poor outcome. Further research is required to ascertain whether targeting an optimal cerebral perfusion pressure may alter outcome.
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Affiliation(s)
- Stephen Copplestone
- a Advanced trainee in Intensive Care Medicine and Anaesthesia , Plymouth Hospitals NHS Trust , Plymouth , UK
| | - Jessie Welbourne
- b Consultant in Intensive Care Medicine and Neuroanaesthesia, Department of Intensive Care Medicine , Plymouth Hospitals NHS Trust , Plymouth , UK
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20
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ICP Monitoring by Open Extraventricular Drainage: Common Practice but Not Suitable for Advanced Neuromonitoring and Prone to False Negativity. ACTA NEUROCHIRURGICA. SUPPLEMENT 2018; 126:281-286. [PMID: 29492575 DOI: 10.1007/978-3-319-65798-1_55] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVE A drawback in the use of an external ventricular drain (EVD) originates in the fact that draining cerebrospinal fluid (CSF) (open system) and intracranial pressure (ICP) monitoring can be done at the same time but is considered to be unreliable regarding the ICP trace. Furthermore, with the more widespread use of autoregulation monitoring using blood pressure and ICP signals, the question arises of whether an ICP signal from an open EVD can be used for this purpose. Using an EVD system with an integrated parenchymal ICP probe we compared the different traces of an ICP signal and their derived parameters under opened and closed CSF drainage. METHODS Twenty patients with either subarachnoid or intraventricular hemorrhage and indication for ventriculostomy plus ICP monitoring received an EVD in combination with an air-pouch-based ICP probe. ICP was monitored via an open ventricular catheter (ICP_evd) and ICP probe (ICP_probe) simultaneously. Neuromonitoring data (ICP, arterial blood pressure, cerebral perfusion pressure, pressure reactivity index (PRx)) were recorded by ICM+ software for the time of ICU intensive care treatment. Routinely (at least every 4 h) ICP was recorded with a closed CSF drainage system for at least 15 min. ICP, ICP amplitude, and the autoregulation parameters (PRx_probe, PRx_evd) were evaluated for every episode with closed CSF drainage and during the 3 h prior with an open drainage system. RESULTS One hundred and forty-four episodes with open/closed drainage were evaluated. During open drainage, overall mean ICP_evd levels were nonsignificantly different from those of ICP_probe, with 9.8 + 3.3 versus 8.2 + 3.2 mmHg, respectively. Limits of agreement ranged between 5.2 and -8.3 mmHg. However, 51 increases of ICP >20 mmHg with a duration of 3-30 min were missed by ICP_evd, and in 101 episodes the difference between ICPs was greater than 10 mmHg. After closure of the EVD, ICP increased moderately using both methods. Mean PRx_evd was significantly higher (falsely indicating impaired autoregulation) and more subjected to fluctuations than PRx_probe. CONCLUSION The general practice of draining CSF and monitoring ICP via a (usually open) EVD plus frequently performed catheter closure for ICP reading is feasible for assessment of overall ICP trends. However, it does have clinically relevant drawbacks, namely, a significant amount of undetected increases in ICP above thresholds, and continuous assessment of cerebrovascular autoregulation is less reliable. In conclusion, all patients who need CSF drainage plus ICP monitoring due to the severity of their brain insult need either an EVD with integrated ICP probe or an EVD line plus a separate ICP probe.
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21
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Johnson U, Engquist H, Lewén A, Howells T, Nilsson P, Ronne-Engström E, Rostami E, Enblad P. Increased risk of critical CBF levels in SAH patients with actual CPP below calculated optimal CPP. Acta Neurochir (Wien) 2017; 159:1065-1071. [PMID: 28361248 PMCID: PMC5425502 DOI: 10.1007/s00701-017-3139-7] [Citation(s) in RCA: 13] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/04/2016] [Accepted: 02/27/2017] [Indexed: 01/23/2023]
Abstract
Background Cerebral pressure autoregulation can be quantified with the pressure reactivity index (PRx), based on the correlation between blood pressure and intracranial pressure. Using PRx optimal cerebral perfusion pressure (CPPopt) can be calculated, i.e., the level of CPP where autoregulation functions best. The relation between cerebral blood flow (CBF) and CPPopt has not been examined. The objective was to assess to which extent CPPopt can be calculated in SAH patients and to investigate CPPopt in relation to CBF. Methods Retrospective study of prospectively collected data. CBF was measured bedside with Xenon-enhanced CT (Xe-CT). The difference between actual CPP and CPPopt was calculated (CPP∆). Correlations between CPP∆ and CBF parameters were calculated with Spearman’s rank order correlation coefficient (rho). Separate calculations were done using all patients (day 0–14 after onset) as well as in two subgroups (day 0–3 and day 4–14). Results Eighty-two patients with 145 Xe-CT scans were studied. Automated calculation of CPPopt was possible in adjunct to 60% of the Xe-CT scans. Actual CPP < CPPopt was associated with higher numbers of low-flow regions (CBF <10 ml/100 g/min) in both the early phase (day 0–3, n = 39, Spearman’s rho = −0.38, p = 0.02) and late acute phase of the disease (day 4–14, n = 35, Spearman’s rho = −0.39, p = 0.02). CPP level per se was not associated with CBF. Conclusions Calculation of CPPopt is possible in a majority of patients with severe SAH. Actual CPP below CPPopt is associated with low CBF.
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Affiliation(s)
- Ulf Johnson
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden.
- Department of Surgical sciences/Radiology, Uppsala University, Uppsala, Sweden.
| | - Henrik Engquist
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
- Department of Surgical sciences/Anaesthesia and Intensive care, Uppsala University, Uppsala, Sweden
| | - Anders Lewén
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | - Tim Howells
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | - Pelle Nilsson
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | | | - Elham Rostami
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
| | - Per Enblad
- Department of Neuroscience/Neurosurgery, Uppsala University, S-75185, Uppsala, Sweden
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