Skip to main content
Erschienen in: Neurocritical Care 2/2012

01.04.2012 | Original Article

Critical Thresholds for Cerebrovascular Reactivity After Traumatic Brain Injury

verfasst von: E. Sorrentino, J. Diedler, M. Kasprowicz, K. P. Budohoski, C. Haubrich, P. Smielewski, J. G. Outtrim, A. Manktelow, P. J. Hutchinson, J. D. Pickard, D. K. Menon, M. Czosnyka

Erschienen in: Neurocritical Care | Ausgabe 2/2012

Einloggen, um Zugang zu erhalten

Abstract

Introduction

Pressure-reactivity index (PRx) is a useful tool in brain monitoring of trauma patients, but the question remains about its critical values. Using our TBI database, we identified the thresholds for PRx and other monitored parameters that maximize the statistical difference between death/survival and favorable/unfavorable outcomes. We also investigated how these thresholds depend on clinical factors such as age, gender and initial GCS.

Methods

A total of 459 patients from our database were eligible. Tables of 2 × 2 format were created grouping patients according to survival/death or favorable/unfavorable outcomes and varying thresholds for PRx, ICP and CPP. Pearson’s chi square was calculated, and the thresholds returning the highest score were assumed to have the best discriminative value. The same procedure was repeated after division according to clinical factors.

Results

In all patients, we found that PRx had different thresholds for survival (0.25) and for favorable outcome (0.05). Thresholds of 70 mmHg for CPP and 22 mmHg for ICP were identified for both survival and favorable outcomes. The ICP threshold for favorable outcome was lower (18 mmHg) in females and patients older than 55 years. In logistic regression models, independent variables associating with mortality and unfavorable outcome were age, GCS, ICP and PRx.

Conclusion

The prognostic role of PRx is confirmed but with a lower threshold of 0.05 for favorable outcome than for survival (0.25). Results for ICP are in line with current guidelines. However, the lower value in elderly and in females suggests increased vulnerability to intracranial hypertension in these groups.
Literatur
1.
Zurück zum Zitat Hyam JA, Welch CA, Harrison DA, Menon DK. Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care. 2006;10:1–11. Hyam JA, Welch CA, Harrison DA, Menon DK. Case mix, outcomes and comparison of risk prediction models for admissions to adult, general and specialist critical care units for head injury: a secondary analysis of the ICNARC Case Mix Programme Database. Crit Care. 2006;10:1–11.
2.
Zurück zum Zitat Jennett B, MacMillan R. Epidemiology of head injury. Br Med J. 1981;282:101–4.CrossRef Jennett B, MacMillan R. Epidemiology of head injury. Br Med J. 1981;282:101–4.CrossRef
3.
Zurück zum Zitat Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5(8):e165, discussion e165.PubMedCrossRef Steyerberg EW, Mushkudiani N, Perel P, et al. Predicting outcome after traumatic brain injury: development and international validation of prognostic scores based on admission characteristics. PLoS Med. 2008;5(8):e165, discussion e165.PubMedCrossRef
4.
Zurück zum Zitat Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. Introduction. J Neurotrauma. 2007;24 Suppl 1:S1–2. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. Introduction. J Neurotrauma. 2007;24 Suppl 1:S1–2.
5.
Zurück zum Zitat Changaris DG, McGraw CP, Richardson JD, Garretson HD, Arpin EJ, Shields CB. Correlation of cerebral perfusion pressure and Glasgow Coma Scale to outcome. J Trauma. 1987;27:1007–13.PubMedCrossRef Changaris DG, McGraw CP, Richardson JD, Garretson HD, Arpin EJ, Shields CB. Correlation of cerebral perfusion pressure and Glasgow Coma Scale to outcome. J Trauma. 1987;27:1007–13.PubMedCrossRef
6.
Zurück zum Zitat Narayan RK, Greenberg RP, Miller JD, et al. Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg. 1981;54:751–62.PubMedCrossRef Narayan RK, Greenberg RP, Miller JD, et al. Improved confidence of outcome prediction in severe head injury. A comparative analysis of the clinical examination, multimodality evoked potentials, CT scanning, and intracranial pressure. J Neurosurg. 1981;54:751–62.PubMedCrossRef
7.
Zurück zum Zitat Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, McConnell et al. Guidelines for the management of severe traumatic brain injury. VIII. Intracranial Pressure thresholds IX. Cerebral perfusion thresholds. J Neurotrauma. 2007;24 Suppl 1:S54–58 and S59–64. Brain Trauma Foundation; American Association of Neurological Surgeons; Congress of Neurological Surgeons; Joint Section on Neurotrauma and Critical Care, AANS/CNS, Bratton SL, Chestnut RM, Ghajar J, McConnell et al. Guidelines for the management of severe traumatic brain injury. VIII. Intracranial Pressure thresholds IX. Cerebral perfusion thresholds. J Neurotrauma. 2007;24 Suppl 1:S54–58 and S59–64.
8.
Zurück zum Zitat Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg. 2001;95:560–8.PubMedCrossRef Contant CF, Valadka AB, Gopinath SP, Hannay HJ, Robertson CS. Adult respiratory distress syndrome: a complication of induced hypertension after severe head injury. J Neurosurg. 2001;95:560–8.PubMedCrossRef
9.
Zurück zum Zitat Young JS, Blow O, Turrentine F, Claridge JA, Schulman A. Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained? Neurosurg Focus. 2003;15(6):E2.PubMedCrossRef Young JS, Blow O, Turrentine F, Claridge JA, Schulman A. Is there an upper limit of intracranial pressure in patients with severe head injury if cerebral perfusion pressure is maintained? Neurosurg Focus. 2003;15(6):E2.PubMedCrossRef
10.
Zurück zum Zitat Brady KM, Shaffner DH, Lee JK, et al. Continuous monitoring of cerebrovascular pressure reactivity after traumatic brain injury in children. Pediatrics. 2009;124(6):e1205–12.PubMedCrossRef Brady KM, Shaffner DH, Lee JK, et al. Continuous monitoring of cerebrovascular pressure reactivity after traumatic brain injury in children. Pediatrics. 2009;124(6):e1205–12.PubMedCrossRef
11.
Zurück zum Zitat Czosnyka M, Smielewski P, Kirkpatrick P, Laing RJ, Menon D, Pickard JD. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery. 1997;41(1):11–7.PubMedCrossRef Czosnyka M, Smielewski P, Kirkpatrick P, Laing RJ, Menon D, Pickard JD. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery. 1997;41(1):11–7.PubMedCrossRef
12.
Zurück zum Zitat Smielewski P, Czosnyka M, Steiner L, Belestri M, Piechnik S, Pickard JD. ICM+: software for on-line analysis of bedside monitoring data after severe head trauma. Acta Neurochir Suppl. 2005;95:43–9.PubMedCrossRef Smielewski P, Czosnyka M, Steiner L, Belestri M, Piechnik S, Pickard JD. ICM+: software for on-line analysis of bedside monitoring data after severe head trauma. Acta Neurochir Suppl. 2005;95:43–9.PubMedCrossRef
13.
Zurück zum Zitat Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28(5):547–53.PubMedCrossRef Patel HC, Menon DK, Tebbs S, Hawker R, Hutchinson PJ, Kirkpatrick PJ. Specialist neurocritical care and outcome from head injury. Intensive Care Med. 2002;28(5):547–53.PubMedCrossRef
14.
Zurück zum Zitat Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. Br J Anaesth. 2007;99(1):32–42.PubMedCrossRef Helmy A, Vizcaychipi M, Gupta AK. Traumatic brain injury: intensive care management. Br J Anaesth. 2007;99(1):32–42.PubMedCrossRef
15.
Zurück zum Zitat Sorrentino E, Budohoski KP, Kasprowicz M, et al. Critical thresholds for transcranial Doppler indices of cerebral autoregulation in traumatic brain injury. Neurocrit Care. 2011;14(2):188–93.PubMedCrossRef Sorrentino E, Budohoski KP, Kasprowicz M, et al. Critical thresholds for transcranial Doppler indices of cerebral autoregulation in traumatic brain injury. Neurocrit Care. 2011;14(2):188–93.PubMedCrossRef
16.
Zurück zum Zitat Nordström CH, Reinstrup P, Xu W, Gärdenfors A, Ungerstedt U. Assessment of the lower limit for cerebral perfusion pressure in severe head injuries by bedside monitoring of regional energy metabolism. Anesthesiology. 2003;98(4):809–14.PubMedCrossRef Nordström CH, Reinstrup P, Xu W, Gärdenfors A, Ungerstedt U. Assessment of the lower limit for cerebral perfusion pressure in severe head injuries by bedside monitoring of regional energy metabolism. Anesthesiology. 2003;98(4):809–14.PubMedCrossRef
17.
Zurück zum Zitat Kiening KL, Unterberg AW, Bardt TF, Schneider GH, Lanksch WR. Monitoring of cerebral oxygenation in patients with severe head injuries: brain tissue PO2 versus jugular vein oxygen saturation. J Neurosurg. 1996;85(5):751–7.PubMedCrossRef Kiening KL, Unterberg AW, Bardt TF, Schneider GH, Lanksch WR. Monitoring of cerebral oxygenation in patients with severe head injuries: brain tissue PO2 versus jugular vein oxygen saturation. J Neurosurg. 1996;85(5):751–7.PubMedCrossRef
18.
Zurück zum Zitat Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92(1):1–6.PubMedCrossRef Juul N, Morris GF, Marshall SB, Marshall LF. Intracranial hypertension and cerebral perfusion pressure: influence on neurological deterioration and outcome in severe head injury. The Executive Committee of the International Selfotel Trial. J Neurosurg. 2000;92(1):1–6.PubMedCrossRef
19.
Zurück zum Zitat Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg. 1995;83(6):949–62.PubMedCrossRef Rosner MJ, Rosner SD, Johnson AH. Cerebral perfusion pressure: management protocol and clinical results. J Neurosurg. 1995;83(6):949–62.PubMedCrossRef
20.
Zurück zum Zitat Chan KH, Miller JD, Dearden NM. The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg. 1992;77(1):55–61.PubMedCrossRef Chan KH, Miller JD, Dearden NM. The effect of changes in cerebral perfusion pressure upon middle cerebral artery blood flow velocity and jugular bulb venous oxygen saturation after severe brain injury. J Neurosurg. 1992;77(1):55–61.PubMedCrossRef
21.
Zurück zum Zitat Vespa P, Prins M, Ronne-Engstrom E, et al. Increase in extracellular glutamate caused by reduced cerebral perfusion pressure and seizures after human traumatic brain injury: a microdialysis study. J Neurosurg. 1998;89(6):971–82.PubMedCrossRef Vespa P, Prins M, Ronne-Engstrom E, et al. Increase in extracellular glutamate caused by reduced cerebral perfusion pressure and seizures after human traumatic brain injury: a microdialysis study. J Neurosurg. 1998;89(6):971–82.PubMedCrossRef
22.
Zurück zum Zitat Howells T, Elf K, Jones PA, et al. Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg. 2005;102:311–7.PubMedCrossRef Howells T, Elf K, Jones PA, et al. Pressure reactivity as a guide in the treatment of cerebral perfusion pressure in patients with brain trauma. J Neurosurg. 2005;102:311–7.PubMedCrossRef
23.
Zurück zum Zitat Steiner LA, Czosnyka M, Piechnik SK, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med. 2002;30(4):733–8.PubMedCrossRef Steiner LA, Czosnyka M, Piechnik SK, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med. 2002;30(4):733–8.PubMedCrossRef
24.
Zurück zum Zitat Menon DK. Procrustes, the traumatic penumbra, and perfusion pressure targets in closed head injury. Anesthesiology. 2003;98(4):805–7.PubMedCrossRef Menon DK. Procrustes, the traumatic penumbra, and perfusion pressure targets in closed head injury. Anesthesiology. 2003;98(4):805–7.PubMedCrossRef
25.
Zurück zum Zitat Vespa P. What is the optimal threshold for cerebral perfusion pressure following traumatic brain injury? Neurosurg Focus. 2003;15(6):E4.PubMedCrossRef Vespa P. What is the optimal threshold for cerebral perfusion pressure following traumatic brain injury? Neurosurg Focus. 2003;15(6):E4.PubMedCrossRef
26.
Zurück zum Zitat Czosnyka M, Balestreri M, Steiner L, et al. Age, intracranial pressure, autoregulation, and outcome after brain trauma. J Neurosurg. 2005;102(3):450–4.PubMedCrossRef Czosnyka M, Balestreri M, Steiner L, et al. Age, intracranial pressure, autoregulation, and outcome after brain trauma. J Neurosurg. 2005;102(3):450–4.PubMedCrossRef
27.
Zurück zum Zitat Czosnyka M, Radolovich D, Balestreri M, Lavinio M, et al. Gender-related differences in intracranial hypertension and outcome after traumatic brain injury. Acta Neurochir Suppl. 2008;102:25–8.PubMedCrossRef Czosnyka M, Radolovich D, Balestreri M, Lavinio M, et al. Gender-related differences in intracranial hypertension and outcome after traumatic brain injury. Acta Neurochir Suppl. 2008;102:25–8.PubMedCrossRef
28.
Zurück zum Zitat Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. 2004;75(1):161–2.PubMed Balestreri M, Czosnyka M, Chatfield DA, et al. Predictive value of Glasgow Coma Scale after brain trauma: change in trend over the past ten years. J Neurol Neurosurg Psychiatry. 2004;75(1):161–2.PubMed
29.
Zurück zum Zitat Castellani G, Zweifel C, Kim DJ, et al. Plateau waves in head injured patients requiring neurocritical care. Neurocrit Care. 2009;11(2):143–50.PubMedCrossRef Castellani G, Zweifel C, Kim DJ, et al. Plateau waves in head injured patients requiring neurocritical care. Neurocrit Care. 2009;11(2):143–50.PubMedCrossRef
30.
Zurück zum Zitat Chambers IR, Treadwell L, Mendelow AD. Determination of threshold levels of cerebral perfusion pressure and intracranial pressure in severe head injury by using receiver-operating characteristic curves: an observational study in 291 patients. J Neurosurg. 2001;94(3):412–6.PubMedCrossRef Chambers IR, Treadwell L, Mendelow AD. Determination of threshold levels of cerebral perfusion pressure and intracranial pressure in severe head injury by using receiver-operating characteristic curves: an observational study in 291 patients. J Neurosurg. 2001;94(3):412–6.PubMedCrossRef
31.
Zurück zum Zitat Wang EC, Ang BT, Wong J, Lim J, Ng I. Characterization of cerebrovascular reactivity after craniectomy for acute brain injury. Br J Neurosurg. 2006;20(1):24–30.PubMedCrossRef Wang EC, Ang BT, Wong J, Lim J, Ng I. Characterization of cerebrovascular reactivity after craniectomy for acute brain injury. Br J Neurosurg. 2006;20(1):24–30.PubMedCrossRef
Metadaten
Titel
Critical Thresholds for Cerebrovascular Reactivity After Traumatic Brain Injury
verfasst von
E. Sorrentino
J. Diedler
M. Kasprowicz
K. P. Budohoski
C. Haubrich
P. Smielewski
J. G. Outtrim
A. Manktelow
P. J. Hutchinson
J. D. Pickard
D. K. Menon
M. Czosnyka
Publikationsdatum
01.04.2012
Verlag
Humana Press Inc
Erschienen in
Neurocritical Care / Ausgabe 2/2012
Print ISSN: 1541-6933
Elektronische ISSN: 1556-0961
DOI
https://doi.org/10.1007/s12028-011-9630-8

Weitere Artikel der Ausgabe 2/2012

Neurocritical Care 2/2012 Zur Ausgabe

Leitlinien kompakt für die Neurologie

Mit medbee Pocketcards sicher entscheiden.

Seit 2022 gehört die medbee GmbH zum Springer Medizin Verlag

Update Neurologie

Bestellen Sie unseren Fach-Newsletter und bleiben Sie gut informiert.