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Klein SP, Decraene B, De Sloovere V, Kempen B, Meyfroidt G, Depreitere B. The Pressure Reactivity Index as a Measure for Cerebrovascular Autoregulation: Validation in a Porcine Cranial Window Model. Neurosurgery 2024:00006123-990000000-01207. [PMID: 38861643 DOI: 10.1227/neu.0000000000003019] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2023] [Accepted: 04/09/2024] [Indexed: 06/13/2024] Open
Abstract
BACKGROUND AND OBJECTIVES Pressure reactivity index (PRx) has been proposed as a metric associated with cerebrovascular autoregulatory (CA) function and has been thoroughly investigated in clinical research. In this study, PRx is validated in a porcine cranial window model, developed to visualize pial arteriolar autoregulation and its limits. METHODS We measured arterial blood pressure, intracranial pressure, pial arteriolar diameter, and red blood cell (RBC) velocity in a closed cranial window piglet model during gradual balloon catheter-induced arterial hypotension (n = 10) or hypertension (n = 10). CA limits were derived through piecewise linear regression of calculated RBC flux vs cerebral perfusion pressure (CPP), leading for each arteriole to 1 lower limit of autoregulation (LLA) and 2 upper limits of autoregulation (ULA1 and ULA2). Autoregulation limits were compared with PRx thresholds, and receiver operating curve analysis was performed with and without CPP binning. A linear mixed effects model of PRx was performed. RESULTS Receiver operating curve analysis indicated an area under the curve (AUC) for LLA prediction by a PRx of 0.65 (95% CI: 0.64-0.67) and 0.77 (95% CI: 0.69-0.86) without and with CPP binning, respectively. The AUC for ULA1 prediction by PRx was 0.69 (95% CI: 0.68-0.69) without and 0.75 (95% CI: 0.68-0.82) with binning. The AUC for ULA2 prediction was 0.55 (95% CI: 0.55-0.58) without and 0.63 (95% CI 0.53-0.72) with binning. The sensitivity and specificity of binned PRx were 65%/90% for LLA, 69%/71% for ULA1, and 59%/74% for ULA2, showing wide interindividual variability. In the linear mixed effects model, pial arteriolar diameter changes were significantly associated with PRx changes (P = .002), whereas RBC velocity (P = .28) and RBC flux (P = .24) were not. CONCLUSION We conclude that PRx is predominantly determined by pial arteriolar diameter changes and moderately predicts CA limits. Performance to detect the CA limits varied highly on an individual level. Active therapeutic strategies based on PRx and the associated correlation metrics should incorporate these limitations.
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Affiliation(s)
- Samuel P Klein
- Neurosurgery Center Limburg, Jessa Hospital, Hasselt, Belgium
| | | | | | - Bavo Kempen
- Neurosurgery, University Hospitals Leuven, Leuven, Belgium
| | - Geert Meyfroidt
- Intensive Care Medicine, University Hospitals Leuven, Leuven, Belgium
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Beqiri E, García-Orellana M, Politi A, Zeiler FA, Placek MM, Fàbregas N, Tas J, De Sloovere V, Czosnyka M, Aries M, Valero R, de Riva N, Smielewski P. Cerebral autoregulation derived blood pressure targets in elective neurosurgery. J Clin Monit Comput 2024; 38:649-662. [PMID: 38238636 DOI: 10.1007/s10877-023-01115-0] [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: 08/27/2023] [Accepted: 11/23/2023] [Indexed: 06/11/2024]
Abstract
Poor postoperative outcomes may be associated with cerebral ischaemia or hyperaemia, caused by episodes of arterial blood pressure (ABP) being outside the range of cerebral autoregulation (CA). Monitoring CA using COx (correlation between slow changes in mean ABP and regional cerebral O2 saturation-rSO2) could allow to individualise the management of ABP to preserve CA. We aimed to explore a continuous automated assessment of ABPOPT (ABP where CA is best preserved) and ABP at the lower limit of autoregulation (LLA) in elective neurosurgery patients. Retrospective analysis of prospectively collected data of 85 patients [median age 60 (IQR 51-68)] undergoing elective neurosurgery. ABPBASELINE was the mean of 3 pre-operative non-invasive measurements. ABP and rSO2 waveforms were processed to estimate COx-derived ABPOPT and LLA trend-lines. We assessed: availability (number of patients where ABPOPT/LLA were available); time required to achieve first values; differences between ABPOPT/LLA and ABP. ABPOPT and LLA availability was 86 and 89%. Median (IQR) time to achieve the first value was 97 (80-155) and 93 (78-122) min for ABPOPT and LLA respectively. Median ABPOPT [75 (69-84)] was lower than ABPBASELINE [90 (84-95)] (p < 0.001, Mann-U test). Patients spent 72 (56-86) % of recorded time with ABP above or below ABPOPT ± 5 mmHg. ABPOPT and ABP time trends and variability were not related to each other within patients. 37.6% of patients had at least 1 hypotensive insult (ABP < LLA) during the monitoring time. It seems possible to assess individualised automated ABP targets during elective neurosurgery.
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Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Marta García-Orellana
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
- Department of Anaesthesiology, Intensive Care and Pain Medicine, Kepler Universitätsklinikum, Neuromed Campus, Linz, Austria
| | - Anna Politi
- Department of Anesthesiology, Intensive Care and Pain Medicine, Milano Bicocca University, San Gerardo Hospital, Monza, Italy
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Univesity of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Price Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Michal M Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Neus Fàbregas
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Jeanette Tas
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Veerle De Sloovere
- Department of Anesthesiology, University Hospitals Leuven, Louvain, Belgium
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Marcel Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care, Maastricht UMC, Maastricht, The Netherlands
| | - Ricard Valero
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Nicolás de Riva
- Neuroanesthesia Division, Anesthesiology Department, Hospital Clinic de Barcelona, Universitat de Barcelona, Barcelona, Spain
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Vanelderen F, Bruyninckx D, Depreitere B. Is age or cardiovascular comorbidity the main predictor of reduced cerebrovascular pressure reactivity in older patients with traumatic brain injury? BRAIN & SPINE 2024; 4:102799. [PMID: 38681173 PMCID: PMC11052909 DOI: 10.1016/j.bas.2024.102799] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 02/09/2024] [Revised: 03/26/2024] [Accepted: 03/31/2024] [Indexed: 05/01/2024]
Abstract
Introduction The Pressure Reactivity index (PRx) has been proposed as a surrogate measure for cerebrovascular autoregulation (CA) and it has been described that older age is associated with worse PRx. The etiology for this reduced capacity remains unknown. Research question To investigate the relation between age and PRx in a cohort of patients with traumatic brain injury (TBI) while correcting for cardiovascular comorbidities. Material and methods This is a retrospective analysis on prospectively collected data in 151 consecutive TBI patients between 2013 and 2023. PRx was averaged over 5 monitoring days and correlated with demographic, patient and injury data. A multiple regression analysis was performed with PRx as dependent variable and cardiovascular comorbidities, age, Glasgow motor score and pupillary reaction as independent variables. A similar model was constructed without age and compared. Results Age, sex, thromboembolic history, arterial hypertension, Glasgow motor score and pupillary reaction significantly correlated with PRx in univariate analysis. In multivariate analysis, age had a significant worsening effect on PRx (p = 0.01), while the cardiovascular risk factors and injury severity had no impact. The comparison of the models with and without age yielded a significant difference (p = 0.01), underpinning the independent effect of age. Discussion and conclusion In the present cohort study in TBI patients it was found that older age independently impaired cerebrovascular pressure reactivity regardless of cardiovascular comorbidity. Pathophysiology of TBI and physiology of ageing seem to line up to synergistically produce a negative effect on brain perfusion.
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Beqiri E, Donnelly J, Aries M, Ercole A, Smielewski P. Continuous monitoring of the lower limit of reactivity in traumatic brain injury patients: understanding what is feasible. Crit Care 2023; 27:488. [PMID: 38082313 PMCID: PMC10714627 DOI: 10.1186/s13054-023-04773-3] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2023] [Accepted: 12/06/2023] [Indexed: 12/18/2023] Open
Affiliation(s)
- Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
- Department of Medicine, University of Auckland, Auckland, New Zealand
| | - Marcel Aries
- School for Mental Health and Neuroscience (MHeNS), University Maastricht, Maastricht, The Netherlands
- Department of Intensive Care Medicine, Maastricht University Medical Center+, Maastricht, The Netherlands
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Svedung Wettervik T, Beqiri E, Bögli SY, Placek M, Guilfoyle MR, Helmy A, Lavinio A, O'Leary R, Hutchinson PJ, Smielewski P. Brain tissue oxygen monitoring in traumatic brain injury: part I-To what extent does PbtO 2 reflect global cerebral physiology? Crit Care 2023; 27:339. [PMID: 37653526 PMCID: PMC10472704 DOI: 10.1186/s13054-023-04627-y] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/25/2023] [Accepted: 08/27/2023] [Indexed: 09/02/2023] Open
Abstract
BACKGROUND The primary aim was to explore the association of global cerebral physiological variables including intracranial pressure (ICP), cerebrovascular reactivity (PRx), cerebral perfusion pressure (CPP), and deviation from the PRx-based optimal CPP value (∆CPPopt; actual CPP-CPPopt) in relation to brain tissue oxygenation (pbtO2) in traumatic brain injury (TBI). METHODS A total of 425 TBI patients with ICP- and pbtO2 monitoring for at least 12 h, who had been treated at the neurocritical care unit, Addenbrooke's Hospital, Cambridge, UK, between 2002 and 2022 were included. Generalized additive models (GAMs) and linear mixed effect models were used to explore the association of ICP, PRx, CPP, and CPPopt in relation to pbtO2. PbtO2 < 20 mmHg, ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, and ∆CPPopt < - 5 mmHg were considered as cerebral insults. RESULTS PbtO2 < 20 mmHg occurred in median during 17% of the monitoring time and in less than 5% in combination with ICP > 20 mmHg, PRx > 0.30, CPP < 60 mmHg, or ∆CPPopt < - 5 mmHg. In GAM analyses, pbtO2 remained around 25 mmHg over a large range of ICP ([0;50] mmHg) and PRx [- 1;1], but deteriorated below 20 mmHg for extremely low CPP below 30 mmHg and ∆CPPopt below - 30 mmHg. In linear mixed effect models, ICP, CPP, PRx, and ∆CPPopt were significantly associated with pbtO2, but the fixed effects could only explain a very small extent of the pbtO2 variation. CONCLUSIONS PbtO2 below 20 mmHg was relatively frequent and often occurred in the absence of disturbances in ICP, PRx, CPP, and ∆CPPopt. There were significant, but weak associations between the global cerebral physiological variables and pbtO2, suggesting that hypoxic pbtO2 is often a complex and independent pathophysiological event. Thus, other variables may be more crucial to explain pbtO2 and, likewise, pbtO2 may not be a suitable outcome measure to determine whether global cerebral blood flow optimization such as CPPopt therapy is successful.
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Affiliation(s)
- Teodor Svedung Wettervik
- Section of Neurosurgery, Department of Medical Sciences, Uppsala University, 751 85, Uppsala, Sweden.
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK.
| | - Erta Beqiri
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Stefan Yu Bögli
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Michal Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
| | - Mathew R Guilfoyle
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Adel Helmy
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Andrea Lavinio
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Ronan O'Leary
- Neurosciences and Trauma Critical Care Unit, Addenbrooke's Hospital, Cambridge University Hospitals, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge, UK
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Dietvorst S, Depreitere B, Meyfroidt G. Beyond intracranial pressure: monitoring cerebral perfusion and autoregulation in severe traumatic brain injury. Curr Opin Crit Care 2023; 29:85-88. [PMID: 36762674 DOI: 10.1097/mcc.0000000000001026] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/11/2023]
Abstract
PURPOSE OF REVIEW Severe traumatic brain injury (TBI) remains the most prevalent neurological condition worldwide. Observational and interventional studies provide evidence to recommend monitoring of intracranial pressure (ICP) in all severe TBI patients. Existing guidelines focus on treating elevated ICP and optimizing cerebral perfusion pressure (CPP), according to fixed universal thresholds. However, both ICP and CPP, their target thresholds, and their interaction, need to be interpreted in a broader picture of cerebral autoregulation, the natural capacity to adjust cerebrovascular resistance to preserve cerebral blood flow in response to external stimuli. RECENT FINDINGS Cerebral autoregulation is often impaired in TBI patients, and monitoring cerebral autoregulation might be useful to develop personalized therapy rather than treatment of one size fits all thresholds and guidelines based on unidimensional static relationships. SUMMARY Today, there is no gold standard available to estimate cerebral autoregulation. Cerebral autoregulation can be triggered by performing a mean arterial pressure (MAP) challenge, in which MAP is increased by 10% for 20 min. The response of ICP (increase or decrease) will estimate the status of cerebral autoregulation and can steer therapy mainly concerning optimizing patient-specific CPP. The role of cerebral metabolic changes and its relationship to cerebral autoregulation is still unclear and awaits further investigation.
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Affiliation(s)
| | | | - Geert Meyfroidt
- Department of Intensive Care, University Hospitals Leuven, Leuven, Belgium
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Megjhani M, Weiss M, Ford J, Terilli K, Kastenholz NCM, Nametz D, Kwon SB, Velazquez A, Agarwal S, Roh DJ, Conzen-Dilger C, Albanna W, Veldeman M, Connolly ES, Claassen J, Aries M, Schubert GA, Park S. Optimal Cerebral Perfusion Pressure and Brain Tissue Oxygen in Aneurysmal Subarachnoid Hemorrhage. Stroke 2023; 54:189-197. [PMID: 36314124 PMCID: PMC9780174 DOI: 10.1161/strokeaha.122.040339] [Citation(s) in RCA: 7] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/15/2022] [Accepted: 09/30/2022] [Indexed: 12/24/2022]
Abstract
BACKGROUND Targeting a cerebral perfusion pressure optimal for cerebral autoregulation (CPPopt) has been gaining more attention to prevent secondary damage after acute neurological injury. Brain tissue oxygenation (PbtO2) can identify insufficient cerebral blood flow and secondary brain injury. Defining the relationship between CPPopt and PbtO2 after aneurysmal subarachnoid hemorrhage may result in (1) mechanistic insights into whether and how CPPopt-based strategies might be beneficial and (2) establishing support for the use of PbtO2 as an adjunctive monitor for adequate or optimal local perfusion. METHODS We performed a retrospective analysis of a prospectively collected 2-center dataset of patients with aneurysmal subarachnoid hemorrhage with or without later diagnosis of delayed cerebral ischemia (DCI). CPPopt was calculated as the cerebral perfusion pressure (CPP) value corresponding to the lowest pressure reactivity index (moving correlation coefficient of mean arterial and intracranial pressure). The relationship of (hourly) deltaCPP (CPP-CPPopt) and PbtO2 was investigated using natural spline regression analysis. Data after DCI diagnosis were excluded. Brain tissue hypoxia was defined as PbtO2 <20 mmHg. RESULTS One hundred thirty-one patients were included with a median of 44.0 (interquartile range, 20.8-78.3) hourly CPPopt/PbtO2 datapoints. The regression plot revealed a nonlinear relationship between PbtO2 and deltaCPP (P<0.001) with PbtO2 decrease with deltaCPP <0 mmHg and stable PbtO2 with deltaCPP ≥0mmHg, although there was substantial individual variation. Brain tissue hypoxia (34.6% of all measurements) was more frequent with deltaCPP <0 mmHg. These dynamics were similar in patients with or without DCI. CONCLUSIONS We found a nonlinear relationship between PbtO2 and deviation of patients' CPP from CPPopt in aneurysmal subarachnoid hemorrhage patients in the pre-DCI period. CPP values below calculated CPPopt were associated with lower PbtO2. Nevertheless, the nature of PbtO2 measurements is complex, and the variability is high. Combined multimodality monitoring with CPP/CPPopt and PbtO2 should be recommended to redefine individual pressure targets (CPP/CPPopt) and retain the option to detect local perfusion deficits during DCI (PbtO2), which cannot be fulfilled by both measurements interchangeably.
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Affiliation(s)
- Murad Megjhani
- Department of Neurology, Columbia University, New York, USA
| | - Miriam Weiss
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Jenna Ford
- Program in Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, USA
| | | | | | - Daniel Nametz
- Department of Neurology, Columbia University, New York, USA
| | - Soon Bin Kwon
- Department of Neurology, Columbia University, New York, USA
| | - Angela Velazquez
- Program in Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, USA
| | - Sachin Agarwal
- Program in Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA
| | - David J. Roh
- Program in Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA
| | | | - Walid Albanna
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - Michael Veldeman
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
| | - E. Sander Connolly
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA
- Department of Neurosurgery, Columbia University, New York, USA
| | - Jan Claassen
- Program in Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA
| | - Marcel Aries
- Department of Intensive Care, Maastricht University Medical Center, Maastricht University, Maastricht, The Netherlands
- School for Mental Health and Neuroscience (MHeNS), Maastricht University Medical Center, Maastricht, The Netherlands
| | - Gerrit A. Schubert
- Department of Neurosurgery, RWTH Aachen University, Aachen, Germany
- Department of Neurosurgery, Kantonsspital Aarau, Aarau, Switzerland
| | - Soojin Park
- Department of Neurology, Columbia University, New York, USA
- Program in Hospital and Intensive Care Informatics, Department of Neurology, Columbia University, New York, USA
- NewYork-Presbyterian Hospital, Columbia University Irving Medical Center, New York, USA
- Department of Biomedical Informatics, Columbia University, New York, USA
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Gomez A, Sekhon M, Griesdale D, Froese L, Yang E, Thelin EP, Raj R, Aries M, Gallagher C, Bernard F, Kramer AH, Zeiler FA. Cerebrovascular pressure reactivity and brain tissue oxygen monitoring provide complementary information regarding the lower and upper limits of cerebral blood flow control in traumatic brain injury: a CAnadian High Resolution-TBI (CAHR-TBI) cohort study. Intensive Care Med Exp 2022; 10:54. [PMID: 36550386 PMCID: PMC9780411 DOI: 10.1186/s40635-022-00482-3] [Citation(s) in RCA: 6] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/07/2022] [Accepted: 12/05/2022] [Indexed: 12/24/2022] Open
Abstract
BACKGROUND Brain tissue oxygen tension (PbtO2) and cerebrovascular pressure reactivity monitoring have emerged as potential modalities to individualize care in moderate and severe traumatic brain injury (TBI). The relationship between these modalities has had limited exploration. The aim of this study was to examine the relationship between PbtO2 and cerebral perfusion pressure (CPP) and how this relationship is modified by the state of cerebrovascular pressure reactivity. METHODS A retrospective multi-institution cohort study utilizing prospectively collected high-resolution physiologic data from the CAnadian High Resolution-TBI (CAHR-TBI) Research Collaborative database collected between 2011 and 2021 was performed. Included in the study were critically ill TBI patients with intracranial pressure (ICP), arterial blood pressure (ABP), and PbtO2 monitoring treated in any one of three CAHR-TBI affiliated adult intensive care units (ICU). The outcome of interest was how PbtO2 and CPP are related over a cohort of TBI patients and how this relationship is modified by the state of cerebrovascular reactivity, as determined using the pressure reactivity index (PRx). RESULTS A total of 77 patients met the study inclusion criteria with a total of 377,744 min of physiologic data available for the analysis. PbtO2 produced a triphasic curve when plotted against CPP like previous population-based plots of cerebral blood flow (CBF) versus CPP. The triphasic curve included a plateau region flanked by regions of relative ischemia (hypoxia) and hyperemia (hyperoxia). The plateau region shortened when cerebrovascular pressure reactivity was disrupted compared to when it was intact. CONCLUSIONS In this exploratory analysis of a multi-institution high-resolution physiology TBI database, PbtO2 seems to have a triphasic relationship with CPP, over the entire cohort. The CPP range over which the plateau exists is modified by the state of cerebrovascular reactivity. This indicates that in critically ill TBI patients admitted to ICU, PbtO2 may be reflective of CBF.
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Affiliation(s)
- Alwyn Gomez
- grid.21613.370000 0004 1936 9609Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ,grid.21613.370000 0004 1936 9609Present Address: Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
| | - Mypinder Sekhon
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada ,grid.17091.3e0000 0001 2288 9830Present Address: Division of Critical Care, Department of Medicine, University of British Columbia, Vancouver, BC Canada
| | - Donald Griesdale
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada
| | - Logan Froese
- grid.21613.370000 0004 1936 9609Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB Canada
| | - Eleen Yang
- grid.17091.3e0000 0001 2288 9830Department of Anesthesiology, Pharmacology & Therapeutics, University of British Columbia, Vancouver, BC Canada
| | - Eric P. Thelin
- grid.24381.3c0000 0000 9241 5705Department of Neurology, Karolinska University Hospital, Stockholm, Sweden ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden
| | - Rahul Raj
- grid.7737.40000 0004 0410 2071Department of Neurosurgery, University of Helsinki and Helsinki University Hospital, Helsinki, Finland
| | - Marcel Aries
- grid.412966.e0000 0004 0480 1382Department of Intensive Care, Maastricht University Medical Center, Maastricht, The Netherlands ,grid.5012.60000 0001 0481 6099School of Mental Health and Neurosciences, University Maastricht, Maastricht, The Netherlands
| | - Clare Gallagher
- grid.22072.350000 0004 1936 7697Section of Neurosurgery, Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Francis Bernard
- grid.14848.310000 0001 2292 3357Section of Critical Care, Department of Medicine, University of Montreal, Montreal, QC Canada
| | - Andreas H. Kramer
- grid.22072.350000 0004 1936 7697Department of Critical Care Medicine, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Department of Clinical Neurosciences, University of Calgary, Calgary, Canada ,grid.22072.350000 0004 1936 7697Hotchkiss Brain Institute, University of Calgary, Calgary, Canada
| | - Frederick A. Zeiler
- grid.21613.370000 0004 1936 9609Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada ,grid.21613.370000 0004 1936 9609Present Address: Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada ,grid.21613.370000 0004 1936 9609Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, MB Canada ,grid.4714.60000 0004 1937 0626Department of Clinical Neuroscience, Karolinska Institutet, Stockholm, Sweden ,grid.21613.370000 0004 1936 9609Centre On Aging, University of Manitoba, Winnipeg, Canada ,grid.5335.00000000121885934Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
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Acharya D, Mukherjea A, Cao J, Ruesch A, Schmitt S, Yang J, Smith MA, Kainerstorfer JM. Non-Invasive Spectroscopy for Measuring Cerebral Tissue Oxygenation and Metabolism as a Function of Cerebral Perfusion Pressure. Metabolites 2022; 12:metabo12070667. [PMID: 35888791 PMCID: PMC9323243 DOI: 10.3390/metabo12070667] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/16/2022] [Revised: 07/14/2022] [Accepted: 07/15/2022] [Indexed: 11/16/2022] Open
Abstract
Near-infrared spectroscopy (NIRS) and diffuse correlation spectroscopy (DCS) measure cerebral hemodynamics, which in turn can be used to assess the cerebral metabolic rate of oxygen (CMRO2) and cerebral autoregulation (CA). However, current mathematical models for CMRO2 estimation make assumptions that break down for cerebral perfusion pressure (CPP)-induced changes in CA. Here, we performed preclinical experiments with controlled changes in CPP while simultaneously measuring NIRS and DCS at rest. We observed changes in arterial oxygen saturation (~10%) and arterial blood volume (~50%) with CPP, two variables often assumed to be constant in CMRO2 estimations. Hence, we propose a general mathematical model that accounts for these variations when estimating CMRO2 and validate its use for CA monitoring on our experimental data. We observed significant changes in the various oxygenation parameters, including the coupling ratio (CMRO2/blood flow) between regions of autoregulation and dysregulation. Our work provides an appropriate model and preliminary experimental evidence for the use of NIRS- and DCS-based tissue oxygenation and metabolism metrics for non-invasive diagnosis of CA health in CPP-altering neuropathologies.
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Affiliation(s)
- Deepshikha Acharya
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Ankita Mukherjea
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Jiaming Cao
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Alexander Ruesch
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Samantha Schmitt
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Jason Yang
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
| | - Matthew A. Smith
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
| | - Jana M. Kainerstorfer
- Department of Biomedical Engineering, Carnegie Mellon University, Pittsburgh, PA 15213, USA; (D.A.); (A.M.); (J.C.); (S.S.); (J.Y.); (M.A.S.)
- Neuroscience Institute, Carnegie Mellon University, Pittsburgh, PA 15213, USA;
- Correspondence:
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Zeiler FA, Aries M, Czosnyka M, Smieleweski P. Cerebral Autoregulation Monitoring in Traumatic Brain Injury: An Overview of Recent Advances in Personalized Medicine. J Neurotrauma 2022; 39:1477-1494. [PMID: 35793108 DOI: 10.1089/neu.2022.0217] [Citation(s) in RCA: 14] [Impact Index Per Article: 7.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/15/2022] Open
Abstract
Impaired cerebral autoregulation (CA) in moderate/severe traumatic brain injury (TBI) has been identified as a strong associate with poor long-term outcomes, with recent data highlighting its dominance over cerebral physiologic dysfunction seen in the acute phase post injury. With advances in bedside continuous cerebral physiologic signal processing, continuously derived metrics of CA capacity have been described over the past two decades, leading to improvements in cerebral physiologic insult detection and development of novel personalized approaches to TBI care in the intensive care unit (ICU). This narrative review focuses on highlighting the concept of continuous CA monitoring and consequences of impairment in moderate/severe TBI. Further, we provide a comprehensive description and overview of the main personalized cerebral physiologic targets, based on CA monitoring, that are emerging as strong associates with patient outcomes. CA-based personalized targets, such as optimal cerebral perfusion pressure (CPPopt), lower/upper limit of regulation (LLR/ULR), and individualized intra-cranial pressure (iICP) are positioned to change the way we care for TBI patients in the ICU, moving away from the "one treatment fits all" paradigm of current guideline-based therapeutic approaches, towards a true personalized medicine approach tailored to the individual patient. Future perspectives regarding research needs in this field are also discussed.
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Affiliation(s)
- Frederick Adam Zeiler
- Health Sciences Centre, Section of Neurosurgery, GB-1 820 Sherbrook Street, Winnipeg, Manitoba, Canada, R3A1R9;
| | - Marcel Aries
- University of Maastricht Medical Center, Department of Intensive Care, Maastricht, Netherlands;
| | - Marek Czosnyka
- university of cambridge, neurosurgery, Canbridge Biomedical Campus, box 167, cambridge, United Kingdom of Great Britain and Northern Ireland, cb237ar;
| | - Peter Smieleweski
- Cambridge University, Neurosurgery, Cambridge, United Kingdom of Great Britain and Northern Ireland;
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11
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Sayin ES, Sobczyk O, Poublanc J, Mikulis DJ, Fisher JA, Kuo KHM, Duffin J. Assessing Cerebrovascular Resistance in Patients With Sickle Cell Disease. Front Physiol 2022; 13:847969. [PMID: 35422710 PMCID: PMC9002264 DOI: 10.3389/fphys.2022.847969] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/03/2022] [Accepted: 03/08/2022] [Indexed: 02/05/2023] Open
Abstract
In patients with sickle cell disease (SCD) the delivery of oxygen to the brain is compromised by anemia, abnormal rheology, and steno-occlusive vascular disease. Meeting demands for oxygen delivery requires compensatory features of brain perfusion. The cerebral vasculature’s regulatory function and reserves can be assessed by observing the flow response to a vasoactive stimulus. In a traditional approach we measured voxel-wise change in Blood Oxygen-Level Dependent (BOLD) MRI signal as a surrogate of cerebral blood flow (CBF) in response to a linear progressive ramping of end-tidal partial pressure of carbon dioxide (PETCO2). Cerebrovascular reactivity (CVR) was defined as ΔBOLD/ΔPETCO2. We used a computer model to fit a virtual sigmoid resistance curve to the progressive CBF response to the stimulus, enabling the calculation of resistance parameters: amplitude, midpoint, range response, resistance sensitivity and vasodilatory reserve. The quality of the resistance sigmoid fit was expressed as the r2 of the fit. We tested 35 patients with SCD, as well as 24 healthy subjects to provide an indication of the normal ranges of the resistance parameters. We found that gray matter CVR and resistance amplitude, range, reserve, and sensitivity are reduced in patients with SCD compared to healthy controls, while resistance midpoint was increased. This study is the first to document resistance measures in adult patients with SCD. It is also the first to score these vascular resistance measures in comparison to the normal range. We anticipate these data will complement the current understanding of the cerebral vascular pathophysiology of SCD, identify paths for therapeutic interventions, and provide biomarkers for monitoring the progress of the disease.
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Affiliation(s)
- Ece Su Sayin
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
| | - Olivia Sobczyk
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory, University Health Network, Toronto, ON, Canada
| | - Julien Poublanc
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory, University Health Network, Toronto, ON, Canada
| | - David J. Mikulis
- Joint Department of Medical Imaging and the Functional Neuroimaging Laboratory, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Joseph A. Fisher
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
- Institute of Medical Sciences, University of Toronto, Toronto, ON, Canada
| | - Kevin H. M. Kuo
- Division of Hematology, Department of Medicine, University of Toronto, Toronto, ON, Canada
| | - James Duffin
- Department of Physiology, University of Toronto, Toronto, ON, Canada
- Department of Anaesthesia and Pain Management, University Health Network, Toronto, ON, Canada
- *Correspondence: James Duffin,
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