A new two-breath technique for extracting the cerebrovascular response to arterial carbon dioxide

Competing influences of arterial pressure and carbon dioxide on the dynamic cerebrovascular response to step transitions in exercise intensity

Recent investigations of middle cerebral artery blood velocity (MCAv) kinetics at the onset of exercise have not accounted for potential dynamic changes in arterial partial pressure of carbon dioxide ([Formula: see text]) during the transient phase of exercise transitions when modeling MCAv kinetics, despite [Formula: see text] having known effects on cerebrovascular tone. The purpose of our study was to determine the independent effects of mean arterial pressure (MAP) and estimated [Formula: see text] ([Formula: see text]) on mean MCAv during repeated moderate-intensity exercise transitions. We hypothesized that cerebral autoregulation would minimize the effect of sustained exercise-induced changes in MAP on mean MCAv and that dynamic changes in [Formula: see text] would contribute to changes in mean MCAv. Eighteen young healthy adults (7 women, age: 28 ± 5 yr) performed three exercise transitions from 25 W to 90% of the ventilatory threshold in sequence with 5-min stages. Mean MCAv increased (P < 0.001) from 25 W (60.5 ± 14.0 cm·s-1) to 90% of the ventilatory threshold (68.8 ± 15.1 cm·s-1). MAP at the level of the middle cerebral artery (MAPMCA) (Δ = 14 ± 8 mmHg, P < 0.001) and [Formula: see text] (Δ = 2.7 ± 1.8 mmHg, P < 0.001) also increased with exercise intensity. Autoregressive moving average (ARMA) analysis isolated the independent effects of dynamic changes in MAPMCA and [Formula: see text] on MCAv, with low prediction error (mean absolute error = 1.12 ± 0.25 cm·s-1). Calculated steady states of the ARMA step responses were 0.13 ± 0.15 cm·s-1·mmHg-1 for Δmean MCAv/ΔMAPMCA and 1.95 ± 0.83 cm·s-1·mmHg-1 for Δmean MCAv/Δ[Formula: see text]. These data demonstrate that the combination of dynamic changes in MAP and [Formula: see text] largely explains the MCAv response during transitions in exercise intensity.NEW & NOTEWORTHY Time-series analysis of moderate-intensity exercise transitions suggested that cerebral autoregulation buffered the effect of sustained changes in mean arterial pressure on middle cerebral artery blood velocity (MCAv) and that changes in estimated arterial partial pressure of carbon dioxide ([Formula: see text]) contributed to the dynamic changes in MCAv during exercise transitions. Therefore, changes in [Formula: see text] at the onset of exercise are central to modeling dynamic MCAv responses and understanding the benefits of exercise on cerebral blood flow.

Predictive value of the transcranial Doppler and mean arterial flow velocity for early detection of cerebral vasospasm in aneurysmal subarachnoid hemorrhage

Objectives

We aimed to predict cerebral vasospasm in acute aneurysmal subarachnoid hemorrhage and to determine the cut-off values of the mean flow velocity by the use of transcranial Doppler.

Methods

A total of 40 patients with acute aneurysmal subarachnoid hemorrhage were included in this study and classified into two groups. The first group was 26 patients (65%) with cerebral vasospasm and the second group was 14 patients (35%) without vasospasm. Initial evaluation using the Glasgow Coma Scale and the severity of aneurysmal subarachnoid hemorrhage was detected by using both the clinical Hunt and Hess and radiological Fisher grading scales. All patients underwent transcranial Doppler evaluations five times in 10 days measuring the mean flow velocities (MFV) of cerebral arteries.

Results

Patients with cerebral vasospasm were associated with significantly higher mean Glasgow Coma Scale score (p = 0.03), significantly higher mean Hunt and Hess scale grades (p = 0.04), with significantly higher mean diabetes mellitus (p = 0.03), significantly higher mean systolic blood pressure and diastolic blood pressure (p = 0.02 and p = 0.005 respectively) and significantly higher MFVs measured within the first 10 days. Logistic regression analysis demonstrated that MFV ≥81 cm/s in the middle cerebral artery is accompanied by an almost five-fold increased risk of vasospasm (OR 4.92, p < 0.01), while MFV ≥63 cm/s in the anterior cerebral artery is accompanied by a three-fold increased risk of vasospasm (OR 3.12, p < 0.01), and MFV ≥42 cm/s in the posterior cerebral artery is accompanied by a two-fold increased risk of vasospasm (OR 2.11, p < 0.05).

Conclusion

Transcranial Doppler is a useful tool for early detection, monitoring, and prediction of post subarachnoid vasospasm and valuable for early therapeutic intervention before irreversible ischemic neurological deficits take place.

Comparisons of the Nonlinear Relationship of Cerebral Blood Flow Response and Cerebral Vasomotor Reactivity to Carbon Dioxide under Hyperventilation between Postural Orthostatic Tachycardia Syndrome Patients and Healthy Subjects

Postural orthostatic tachycardia syndrome (POTS) typically occurs in youths, and early accurate POTS diagnosis is challenging. A recent hypothesis suggests that upright cognitive impairment in POTS occurs because reduced cerebral blood flow velocity (CBFV) and cerebrovascular response to carbon dioxide (CO₂) are nonlinear during transient changes in end-tidal CO₂ (P_ETCO2). This novel study aimed to reveal the interaction between cerebral autoregulation and ventilatory control in POTS patients by using tilt table and hyperventilation to alter the CO₂ tension between 10 and 30 mmHg. The cerebral blood flow velocity (CBFV), partial pressure of end-tidal carbon dioxide (P_ETCO2), and other cardiopulmonary signals were recorded for POTS patients and two healthy groups including those aged >45 years (Healthy-Elder) and aged <45 years (Healthy-Youth) throughout the experiment. Two nonlinear regression functions, Models I and II, were applied to evaluate their CBFV-P_ETCO2 relationship and cerebral vasomotor reactivity (CVMR). Among the estimated parameters, the curve-fitting Model I for CBFV and CVMR responses to CO₂ for POTS patients demonstrated an observable dissimilarity in CBFV_max (p = 0.011), mid-P_ETCO2 (p = 0.013), and P_ETCO2 range (p = 0.023) compared with those of Healthy-Youth and in CBFV_max (p = 0.015) and CVMR_max compared with those of Healthy-Elder. With curve-fitting Model II for POTS patients, the fit parameters of curvilinear (p = 0.036) and P_ETCO2 level (p = 0.033) displayed significant difference in comparison with Healthy-Youth parameters; range of change (p = 0.042), P_ETCO2 level, and CBFV_max also displayed a significant difference in comparison with Healthy-Elder parameters. The results of this study contribute toward developing an early accurate diagnosis of impaired CBFV responses to CO₂ for POTS patients.

Cerebrovascular autoregulation: lessons learned from spaceflight research

This review summarizes our current understanding of cerebral blood flow regulation with exposure to microgravity, outlines potential mechanisms associated with post-flight orthostatic intolerance, and proposes future directions for research and linkages with cerebrovascular disorders found in the general population. It encompasses research from cellular mechanisms (e.g. hind limb suspension: tissue, animal studies) to whole body analysis with respect to understanding human responses using space analogue studies (bed rest, parabolic flight) as well as data collected before, during, and after spaceflight. Recent evidence indicates that cerebrovascular autoregulation may be impaired in some astronauts leading to increased susceptibility to syncope upon return to a gravitational environment. The proposed review not only provides insights into the mechanisms of post-flight orthostatic intolerance, but also increases our understanding of the mechanisms associated with pathophysiological conditions (e.g. unexplained syncope) with clinical applications in relation to postural hypotension or intradialytic hypotension.

Impaired cerebrovascular autoregulation and reduced CO2 reactivity after long duration spaceflight

Long duration habitation on the International Space Station (ISS) is associated with chronic elevations in arterial blood pressure in the brain compared with normal upright posture on Earth and elevated inspired CO2. Although results from short-duration spaceflights suggested possibly improved cerebrovascular autoregulation, animal models provided evidence of structural and functional changes in cerebral vessels that might negatively impact autoregulation with longer periods in microgravity. Seven astronauts (1 woman) spent 147 ± 49 days on ISS. Preflight testing (30–60 days before launch) was compared with postflight testing on landing day ( n = 4) or the morning 1 ( n = 2) or 2 days ( n = 1) after return to Earth. Arterial blood pressure at the level of the middle cerebral artery (BPMCA) and expired CO2 were monitored along with transcranial Doppler ultrasound assessment of middle cerebral artery (MCA) blood flow velocity (CBFV). Cerebrovascular resistance index was calculated as (CVRi = BPMCA/CBFV). Cerebrovascular autoregulation and CO2 reactivity were assessed in a supine position from an autoregressive moving average (ARMA) model of data obtained during a test where two breaths of 10% CO2 were given four times during a 5-min period. CBFV and Doppler pulsatility index were reduced during −20 mmHg lower body negative pressure, with no differences pre- to postflight. The postflight indicator of dynamic autoregulation from the ARMA model revealed reduced gain for the CVRi response to BPMCA ( P = 0.017). The postflight responses to CO2 were reduced for CBFV ( P = 0.056) and CVRi ( P = 0.047). These results indicate that long duration missions on the ISS impaired dynamic cerebrovascular autoregulation and reduced cerebrovascular CO2 reactivity.

The influence of calculation method on estimates of cerebral critical closing pressure

The critical closing pressure (CrCP) of cerebral circulation is normally estimated by extrapolation of instantaneous velocity-pressure curves. Different methods of estimation were analysed to assess their robustness and reproducibility in both static and dynamic applications. In ten healthy subjects (mean ± SD age 37.5 ± 9.2 years) continuous recordings of arterial blood pressure (BP, Finapres) and bilateral cerebral blood flow velocity (transcranial Doppler ultrasound, middle cerebral arteries) were obtained at rest. Each session consisted of three separate 5 min recordings. A total of four recording sessions for each subject took place over a 2 week period. A total of 117 recordings contained 34 014 cardiac cycles. For each cardiac cycle, CrCP and resistance-area product (RAP) were estimated using linear regression (LR), principal component analysis (PCA), first harmonic fitting (H1), 2-point systolic/diastolic values (2Ps) and 2-point mean/diastolic values (2Pm). LR and PCA were also applied using only the diastolic phase (LRd, PCAd). The mean values of CrCP and RAP for the entire 5 min recording ('static' condition) were not significantly different for LRd, PCAd, H1 and 2Pm, as opposed to the other methods. The same four methods provided the best results regarding the absence of negative values of CrCP and the coefficient of variation (CV) of the intra-subject standard error of the mean (SEM). On the other hand, 'dynamic' applications, such as the transfer function between mean BP and RAP (coherence and RAP step response) led to a different ranking of methods, but without significant differences in CV SEM coherence. For the CV of the RAP step response though, LRd and PCAd performed badly. These results suggest that H1 or 2Pm perform better than LR analysis and should be used for the estimation of CrCP and RAP for both static and dynamic applications.

Cerebral vasomotor reactivity before and after blood pressure reduction in hypertensive patients

BACKGROUND

Hypertension is associated with cerebrovascular remodeling and endothelial dysfunction, which may reduce cerebral vasomotor reactivity to CO2. Treatment combining blood pressure (BP) reduction with inhibition of vascular effects of angiotensin II may reverse these changes. However, the reduction in BP at the onset of treatment can compromise cerebral perfusion and exhaust vasomotor reserve, leading to impaired CO2 reactivity.

METHODS

Eleven patients (nine men, two women) with newly diagnosed, untreated mild-to-moderate hypertension aged (mean (s.d.)) 52 (9) years, and eight controls (seven men, one woman) aged 46 (10) years were studied. Patients received losartan/hydrochlorothiazide (50/12.5 or 100/25 mg) to reduce BP to <140/<90 mm Hg within 1-2 weeks. BP (Finapres), heart rate (HR), CBFV (cerebral blood flow velocity, transcranial Doppler), cerebrovascular resistance, and CO2 reactivity were measured at baseline, after the rapid BP reduction, and after long-term treatment (3-4 months).

RESULTS

At baseline, hypertension was not associated with reduced CO2 reactivity. Treatment effectively lowered BP from 148 (12)/89 (7) to 130 (15)/80 (9) after 1-2 weeks and 125 (10)/77 (7) mm Hg after 3-4 months (P = 0.003). CO2 reactivity was not affected by the reduction in BP within 2 weeks, and long-term treatment did not augment reactivity.

CONCLUSIONS

In hypertension without diabetes or advanced cerebrovascular disease, CO2 reactivity is not reduced, and rapid normalization (within 2 weeks) of BP does not exhaust vasomotor reserve. CO2 reactivity did not change between 2 and 12 weeks of treatment, which argues against a direct vascular effect of angiotensin II inhibition within this period.

Integration of cerebrovascular CO2 reactivity and chemoreflex control of breathing: mechanisms of regulation, measurement, and interpretation

Cerebral blood flow (CBF) and its distribution are highly sensitive to changes in the partial pressure of arterial CO(2) (Pa(CO(2))). This physiological response, termed cerebrovascular CO(2) reactivity, is a vital homeostatic function that helps regulate and maintain central pH and, therefore, affects the respiratory central chemoreceptor stimulus. CBF increases with hypercapnia to wash out CO(2) from brain tissue, thereby attenuating the rise in central Pco(2), whereas hypocapnia causes cerebral vasoconstriction, which reduces CBF and attenuates the fall of brain tissue Pco(2). Cerebrovascular reactivity and ventilatory response to Pa(CO(2)) are therefore tightly linked, so that the regulation of CBF has an important role in stabilizing breathing during fluctuating levels of chemical stimuli. Indeed, recent reports indicate that cerebrovascular responsiveness to CO(2), primarily via its effects at the level of the central chemoreceptors, is an important determinant of eupneic and hypercapnic ventilatory responsiveness in otherwise healthy humans during wakefulness, sleep, and exercise and at high altitude. In particular, reductions in cerebrovascular responsiveness to CO(2) that provoke an increase in the gain of the chemoreflex control of breathing may underpin breathing instability during central sleep apnea in patients with congestive heart failure and on ascent to high altitude. In this review, we summarize the major factors that regulate CBF to emphasize the integrated mechanisms, in addition to Pa(CO(2)), that control CBF. We discuss in detail the assessment and interpretation of cerebrovascular reactivity to CO(2). Next, we provide a detailed update on the integration of the role of cerebrovascular CO(2) reactivity and CBF in regulation of chemoreflex control of breathing in health and disease. Finally, we describe the use of a newly developed steady-state modeling approach to examine the effects of changes in CBF on the chemoreflex control of breathing and suggest avenues for future research.

Alterations in autonomic function and cerebral hemodynamics to orthostatic challenge following a mountain marathon

We examined potential mechanisms (autonomic function, hypotension, and cerebral hypoperfusion) responsible for orthostatic intolerance following prolonged exercise. Autonomic function and cerebral hemodynamics were monitored in seven athletes pre-, post- (<4 h), and 48 h following a mountain marathon [42.2 km; cumulative gain ∼1,000 m; ∼15°C; completion time, 261 ± 27 (SD) min]. In each condition, middle cerebral artery blood velocity (MCAv), blood pressure (BP), heart rate (HR), and cardiac output (Modelflow) were measured continuously before and during a 6-min stand. Measurements of HR and BP variability and time-domain analysis were used as an index of sympathovagal balance and baroreflex sensitivity (BRS). Cerebral autoregulation was assessed using transfer-function gain and phase shift in BP and MCAv. Hypotension was evident following the marathon during supine rest and on standing despite increased sympathetic and reduced parasympathetic control, and elevations in HR and cardiac output. On standing, following the marathon, there was less elevation in normalized low-frequency HR variability ( P < 0.05), indicating attenuated sympathetic activation. MCAv was maintained while supine but reduced during orthostasis postmarathon [−10.4 ± 9.8% pre- vs. −15.4 ± 9.9% postmarathon (%change from supine); P < 0.05]; such reductions were related to an attenuation in BRS ( r = 0.81; P < 0.05). Cerebral autoregulation was unchanged following the marathon. These findings indicate that following prolonged exercise, hypotension and postural reductions in autonomic function or baroreflex control, or both, rather than a compromise in cerebral autoregulation, may place the brain at risk of hypoperfusion. Such changes may be critical factors in collapse following prolonged exercise.

Transcranial Doppler estimation of cerebral blood flow and cerebrovascular conductance during modified rebreathing

Clinical transcranial Doppler assessment of cerebral vasomotor reactivity (CVMR) uses linear regression of cerebral blood flow velocity (CBFV) vs. end-tidal CO(2) (Pet(CO(2))) under steady-state conditions. However, the cerebral blood flow (CBF)-Pet(CO(2)) relationship is nonlinear, even for moderate changes in CO(2). Moreover, CBF is increased by increases in arterial blood pressure (ABP) during hypercapnia. We used a modified rebreathing protocol to estimate CVMR during transient breath-by-breath changes in CBFV and Pet(CO(2)). Ten healthy subjects (6 men) performed 15 s of hyperventilation followed by 5 min of rebreathing, with supplemental O(2) to maintain arterial oxygen saturation constant. To minimize effects of changes in ABP on CVMR estimation, cerebrovascular conductance index (CVCi) was calculated. CBFV-Pet(CO(2)) and CVCi-Pet(CO(2)) relationships were quantified by both linear and nonlinear logistic regression. In three subjects, muscle sympathetic nerve activity was recorded. From hyperventilation to rebreathing, robust changes occurred in Pet(CO(2)) (20-61 Torr), CBFV (-44 to +104% of baseline), CVCi (-39 to +64%), and ABP (-19 to +23%) (all P < 0.01). Muscle sympathetic nerve activity increased by 446% during hypercapnia. The linear regression slope of CVCi vs. Pet(CO(2)) was less steep than that of CBFV (3 vs. 5%/Torr; P = 0.01). Logistic regression of CBF-Pet(CO(2)) (r(2) = 0.97) and CVCi-Pet(CO(2)) (r(2) = 0.93) was superior to linear regression (r(2) = 0.91, r(2) = 0.85; P = 0.01). CVMR was maximal (6-8%/Torr) for Pet(CO(2)) of 40-50 Torr. In conclusion, CBFV and CVCi responses to transient changes in Pet(CO(2)) can be described by a nonlinear logistic function, indicating that CVMR estimation varies within the range from hypocapnia to hypercapnia. Furthermore, quantification of the CVCi-Pet(CO(2)) relationship may minimize the effects of changes in ABP on the estimation of CVMR. The method developed provides insight into CVMR under transient breath-by-breath changes in CO(2).

Cerebral hemodynamics during orthostatic stress assessed by nonlinear modeling

The effects of orthostatic stress, induced by lower body negative pressure (LBNP), on cerebral hemodynamics were examined in a nonlinear context. Spontaneous fluctuations of beat-to-beat mean arterial blood pressure (MABP) in the finger, mean cerebral blood flow velocity (MCBFV) in the middle cerebral artery, as well as breath-by-breath end-tidal CO2 concentration (PetCO2) were measured continuously in 10 healthy subjects under resting conditions and during graded LBNP to presyncope. A two-input nonlinear Laguerre-Volterra network model was employed to study the dynamic effects of MABP and PetCO2 changes, as well as their nonlinear interactions, on MCBFV variations in the very low (VLF; below 0.04 Hz), low (LF; 0.04–0.15 Hz), and high frequency (HF; 0.15–0.30 Hz) ranges. Dynamic cerebral autoregulation was described by the model terms corresponding to MABP, whereas cerebral vasomotor reactivity was described by the model PetCO2 terms. The nonlinear model terms reduced the output prediction normalized mean square error substantially (by 15–20%) and had a prominent effect in the VLF range, both under resting conditions and during LBNP. Whereas MABP fluctuations dominated in the HF range and played a significant role in the VLF and LF ranges, changes in PetCO2 accounted for a considerable fraction of the VLF and LF MCBFV variations, especially at high LBNP levels. The magnitude of the linear and nonlinear MABP-MCBFV Volterra kernels increased substantially above −30 mmHg LBNP in the VLF range, implying impaired dynamic autoregulation. In contrast, the magnitude of the PetCO2-MCBFV kernels reduced during LBNP at all frequencies, suggesting attenuated cerebral vasomotor reactivity under dynamic conditions. We speculate that these changes may reflect a progressively reduced cerebrovascular reserve to compensate for the increasingly unstable systemic circulation during orthostatic stress that could ultimately lead to cerebral hypoperfusion and syncope.

Dynamic cerebral autoregulation during brain activation paradigms

Dynamic cerebral autoregulation (CA) describes the transient response of cerebral blood flow (CBF) to rapid changes in arterial blood pressure (ABP). We tested the hypothesis that the efficiency of dynamic CA is increased by brain activation paradigms designed to induce hemispheric lateralization. CBF velocity [CBFV; bilateral, middle cerebral artery (MCA)], ABP, ECG, and end-tidal Pco2 were continuously recorded in 14 right-handed healthy subjects (21–43 yr of age), in the seated position, at rest and during 10 repeated presentations (30 s on-off) of a word generation test and a constructional puzzle. Nonstationarities were not found during rest or activation. Transfer function analysis of the ABP-CBFV (i.e., input-output) relation was performed for the 10 separate 51.2-s segments of data during activation and compared with baseline data. During activation, the coherence function below 0.05 Hz was significantly increased for the right MCA recordings for the puzzle tasks compared with baseline values (0.36 ± 0.16 vs. 0.26 ± 0.13, P < 0.05) and for the left MCA recordings for the word paradigm (0.48 ± 0.23 vs. 0.29 ± 0.16, P < 0.05). In the same frequency range, significant increases in gain were observed during the puzzle paradigm for the right (0.69 ± 0.37 vs. 0.46 ± 0.32 cm·s−1·mmHg−1, P < 0.05) and left (0.61 ± 0.29 vs. 0.45 ± 0.24 cm·s−1·mmHg−1, P < 0.05) hemispheres and during the word tasks for the left hemisphere (0.66 ± 0.31 vs. 0.39 ± 0.15 cm·s−1·mmHg−1, P < 0.01). Significant reductions in phase were observed during activation with the puzzle task for the right (−0.04 ± 1.01 vs. 0.80 ± 0.86 rad, P < 0.01) and left (0.11 ± 0.81 vs. 0.57 ± 0.51 rad, P < 0.05) hemispheres and with the word paradigm for the right hemisphere (0.05 ± 0.87 vs. 0.64 ± 0.59 rad, P < 0.05). Brain activation also led to changes in the temporal pattern of the CBFV step response. We conclude that transfer function analysis suggests important changes in dynamic CA during mental activation tasks.

Cerebral pressure-flow relations in hypertensive elderly humans: transfer gain in different frequency domains

The dynamics of the cerebral vascular response to blood pressure changes in hypertensive humans is poorly understood. Because cerebral blood flow is dependent on adequate perfusion pressure, it is important to understand the effect of hypertension on the transfer of pressure to flow in the cerebrovascular system of elderly people. Therefore, we examined the effect of spontaneous and induced blood pressure changes on beat-to-beat and within-beat cerebral blood flow in three groups of elderly people: normotensive, controlled hypertensive, and uncontrolled hypertensive subjects. Cerebral blood flow velocity (transcranial Doppler), blood pressure (Finapres), heart rate, and end-tidal CO(2) were measured during the transition from a sit to stand position. Transfer function gains relating blood pressure to cerebral blood flow velocity were assessed during steady-state sitting and standing. Cerebral blood flow regulation was preserved in all three groups by using changes in cerebrovascular resistance, transfer function gains, and the autoregulatory index as indexes of cerebral autoregulation. Hypertensive subjects demonstrated better attenuation of cerebral blood flow fluctuations in response to blood pressure changes both within the beat (i.e., lower gain at the cardiac frequency) and in the low-frequency range (autoregulatory, 0.03-0.07 Hz). Despite a better pressure autoregulatory response, hypertensive subjects demonstrated reduced reactivity to CO(2). Thus otherwise healthy hypertensive elderly subjects, whether controlled or uncontrolled with antihypertensive medication, retain the ability to maintain cerebral blood flow in the face of acute changes in perfusion pressure. Pressure regulation of cerebral blood flow is unrelated to cerebrovascular reactivity to CO(2).

Two-breath CO2 test detects altered dynamic cerebrovascular autoregulation and CO2 responsiveness with changes in arterial Pco2

The new two-breath CO2 method was employed to test the hypotheses that small alterations in arterial Pco2 had an impact on the magnitude and dynamic response time of the CO2 effect on cerebrovascular resistance (CVRi) and the dynamic autoregulatory response to fluctuations in arterial pressure. During a 10-min protocol, eight subjects inspired two breaths from a bag with elevated Pco2, four different times, while end-tidal Pco2 was maintained at three levels: hypocapnia (LoCO2, 8 mmHg below resting values), normocapnia, and hypercapnia (HiCO2, 8 mmHg above resting values). Continuous measurements were made of mean blood pressure corrected to the level of the middle cerebral artery (BPMCA), Pco2 (estimated from expired CO2), and mean flow velocity (MFV, of the middle cerebral artery by Doppler ultrasound), with CVRi = BPMCA/MFV. Data were processed by a system identification technique (autoregressive moving average analysis) with gain and dynamic response time of adaptation estimated from the theoretical step responses. Consistent with our hypotheses, the magnitude of the Pco2-CVRi response was reduced from LoCO2 to HiCO2 [from −0.04 (SD 0.02) to −0.01 (SD 0.01) (mmHg·cm−1·s)·mmHg Pco2−1] and the time to reach 95% of the step plateau increased from 12.0 ± 4.9 to 20.5 ± 10.6 s. Dynamic autoregulation was impaired with elevated Pco2, as indicated by a reduction in gain from LoCO2 to HiCO2 [from 0.021 ± 0.012 to 0.007 ± 0.004 (mmHg·cm−1·s)·mmHg BPMCA−1], and time to reach 95% increased from 3.7 ± 2.8 to 20.0 ± 9.6 s. The two-breath technique detected dependence of the cerebrovascular CO2 response on Pco2 and changes in dynamic autoregulation with only small deviations in estimated arterial Pco2.