Dynamic Cerebral Autoregulation in Patients with Ruptured and Unruptured Aneurysms after Induction of General Anesthesia

 

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Abstract

Introduction: Blood pressure management in patients undergoing surgery for clipping of aneurysms is demanding. More information about the ability of cerebral vessels to normally regulate cerebral blood flow may have a direct influence on the intraoperative management. In patients with subarachnoid hemorrhage (SAH) a disturbance of cerebral autoregulation has been reported and it correlated with the severity of the bleeding in these studies. The impairment of autoregulation was demonstrated using static measurements of cerebral pressure autoregulation. However, the dynamic component of the autoregulatory capacity seems to be of importance in the acute setting after SAH. The aim of this study was to evaluate dynamic pressure autoregulation in patients undergoing surgery for intracranial aneurysms. Patients/Material and Methods: 36 patients with a mean age of 45 years were evaluated, 26 patients with acute SAH, 10 patients with unruptured aneurysms. Cerebral autoregulation in normocapnia was tested using thigh cuffs to alter arterial blood pressure and continuous registration of the blood flow velocities with transcranial Doppler sonography. After the induction of general anesthesia under normocapnia the autoregulatory index (ARI) was calculated (values between 0-9). Patient groups were compared using Wilcoxon- and Spearman's rank test. Results: The two patient groups were comparable with regard to gender, age, PaCO₂, blood flow velocities and blood pressure. In patients with SAH mean ARI was 3.1/3.3 (right/left side) compared to 4.7/4.6 (right/left side) in patients without SAH. The difference was statistically significant (Wilcoxon p = 0.0399). The degree of impairmant of the autoregulatory capacity increased significantly (p = 0.006) with the severity of the SAH (Hunt&Hess and Fisher scale). Conclusion: Dynamic pressure autoregulation is impaired in patients after SAH compared to patients without SAH and correlates with the severity of the SAH. We propose that autoregulation should be measured in all patients with SAH or that an impaired autoregulation should be taken into account in patients with SAH undergoing surgery in the acute phase.

Zusammenfassung

Einleitung: Das Blutdruckmanagement bei Aneurysmaoperationen ist anspruchsvoll. Informationen über den Status der Autoregulation sind wichtig und hilfreich und haben direkten Einfluss auf das intraoperative Management. Patienten mit Subarachnoidalblutung (SAB) zeigen in Abhängigkeit von der Schwere der Blutung eine Störung der Autoregulation. Diese Ergebnisse wurden durch Bestimmung der statischen Autoregulation gewonnen. Allerdings scheint die dynamische Komponente der Autoregulation für die Akutphase nach SAB ebenso von Bedeutung zu sein. Dementsprechend war das Ziel dieser Untersuchung, die dynamische Autoregulation bei Patienten mit rupturierten und nicht rupturierten Aneurysmen in Narkose zu bestimmen. Patienten/Material und Methoden: 36 Patienten mit einem Durchschnittsalter von 45 Jahren, davon 26 mit stattgehabter SAB und 10 Patienten mit nicht rupturierten Aneurysmen wurden untersucht. In Narkose und Normokapnie wurde mit Hilfe der transkraniellen Doppler-Sonographie und Oberschenkeldruckmanschetten die dynamische zerebrale Autoregulation bestimmt. Der Autoregulations-Index (ARI) wurde errechnet (Werte zwischen 0-9). Die Werte wurden zwischen den beiden Patientengruppen mit Hilfe des Wilcoxon- und des Spearman-Rang-Tests verglichen. Ergebnisse: Patienten mit rupturierten und innozenten Aneurysmen zeigten bezogen auf das Geschlecht, Alter, paCO₂-Wert, Blutfließgeschwindigkeiten und Blutdruck keine Unterschiede. Bei Patienten mit SAB lag der ARI bei 3,1/3,3 (rechts/links), während er bei Patienten mit innozenten Aneurysmen bei 4,7/4,6 (rechts/links) lag. Die Differenz war statistisch signifikant (Wilcoxon p = 0,0399). Das Ausmaß der Autoregulationsstörung nahm zudem statistisch signifikant (p = 0,006) mit dem Schweregrad der SAB zu (Hunt&Hess und/oder Fisher-Skala). Schlussfolgerung: Die dynamische zerebrale Autoregulation ist bei Patienten mit SAB in Abhängigkeit vom Schweregrad der SAB gestört. Dementsprechend sollte die dynamische Komponente der Autoregulation bei Patienten mit SAB gemessen werden. Alternativ muss eine Störung der Autoregulation bei Patienten mit schwereren Blutungen im Akutmanagement Berücksichtigung finden.

References

• 1 Aaslid R, Lindegaard K F, Sorteberg W, Nornes H. Cerebral autoregulation dynamics in humans.  Stroke. 1989;  20 45-52
  CrossrefPubMedGoogle Scholar
• 2 Birch A A, Dirnhuber M J, Hartley-Davies R, Iannotti F, Neil-Dwyer G. Assessment of autoregulation by means of periodic changes in blood pressure.  Stroke. 1995;  26 834-837
  PubMedGoogle Scholar
• 3 Dawson S L, Panarai R B, Potter J F. Serial changes in static and dynamic cerebral autoregulation after ischaemic stroke.  Cerebrovasc Dis. 2003;  16 69-75
  CrossrefPubMedGoogle Scholar
• 4 Edwards M R, Devitt D L, Hughson R L. Two breath CO₂ test detects altered dynamic cerebrovascular autoregulation and CO₂ responsiveness with changes in arteriel PCO₂.  Am J Physiol Regul Integr Comp Physiol. 2004;  287 627-632
  PubMedGoogle Scholar
• 5 Endoh H, Honda T, Komura N, Shibue C, Watanabe I, Shimoji K. The effects of nicardipine on dynamic cerebral autoregulation in patients anesthetized with propofol and fentanyl.  Anesth Anallog. 2000;  91 642-646
  PubMedGoogle Scholar
• 6 Graf B M, Böhrer H. Letale hypertensive Reaktion während der Anästhesie bei einer Patientin mit akuter Subarachnoidalblutung.  Anaesthesist. 1990;  39 434-438
  PubMedGoogle Scholar
• 7 Giller C A. The frequency-dependent behavior of cerebral autoregulation.  Neurosurgery. 1990;  27 362-368
  PubMedGoogle Scholar
• 8 Handa Y, Hayashi M, Takeuchi H, Kubota T, Kobayashi H, Kawano H. Time course of the impairment of cerebral autoregulation during chronic cerebral vasospasm after subarachnoid hemorrhage in primates.  J Neurosurg. 1992;  76 493-501
  PubMedGoogle Scholar
• 9 Harper A M. Autoregulation of cerebral blood flow: Influence of arterial blood pressure on the blood flow through the cerebral cortex.  J Neurol Neurosurg Pyschiat. 1966;  29 398-403
  PubMedGoogle Scholar
• 10 Harrison J M, Girling K J, Mahajan R P. Effects of target-controlled infusion of propofol on the transient hyperaemic response and carbon dioxide reactivity in the middle cerebral artery.  Br J Anaesth. 1999;  83 839-844
  PubMedGoogle Scholar
• 11 Heuer G G, Smith M J, Elliott J P, Winn H R, LeRoux P D. Relationship between intracranial pressure and other clinical variables in patients with aneurysmal subarachnoid hemorrhage.  J Neurosurg. 2004;  101 408-416
  CrossrefPubMedGoogle Scholar
• 12 Hlatky H, Furuya Y, Valadka A B, Gonzales J, Chacko A, Mizutani Y, Contant C F, Robertson C S. Dynamic autoregulatory response after severe head injury.  J Neurosurg. 2002;  97 1054-1061
  PubMedGoogle Scholar
• 13 Jünger E C, Newell D W, Grant G A, Avellino A M, Ghatan S, Douville C M, Lam A M, Aaslid R, Winn H R. Cerebral autoregulation following minor head injury.  J Neurosurg. 1997;  86 425-432
  PubMedGoogle Scholar
• 14 Kontos H A, Wie E P, Navari R M, Levasseur J E, Rosenblum W I, Patterson J L. Responses of cerebral arteries and arterioles to acute hypotension and hypertension.  Am J Physiol. 1977;  234 371-383
  PubMedGoogle Scholar
• 15 Lang E W, Diehl R R, Mehdorn H M. Cerebral autoregulation testing after aneurysmal subarachnoid hemorrhage: the phase relationship between arterial blood pressure and cerebral blood flow velocity.  Crit Care Med. 2001;  1 158-163
  PubMedGoogle Scholar
• 16 Mahony P J, Panerai R B, Deverson S T, Hayes P D, Evans D H. Assessment of the thigh cuff technique for measurement of dynamic cerebral autoregulation.  Stroke. 2000;  31 476-480
  PubMedGoogle Scholar
• 17 Marion D W, Bouma G J. The use of stable Xenon-enhanced computed tomographic studies of cerebral blood flow to define changes in cerebral carbon dioxide vasoresponsivity caused by a severe head injury.  Neurosurgery. 1991;  29 869-873
  PubMedGoogle Scholar
• 18 Newell D W, Aaslid R, Lam A, Mayberg T S, Winn H R. Comparison of flow and velocity during dynamic autoregulation testing in humans.  Stroke. 1994;  25 793-797
  PubMedGoogle Scholar
• 19 Newell D W, Weber J P, Watson R. Effect of transient moderate hyperventilation on dynamic cerebral autoregulation after severe head injury.  Neurosurgery. 1996;  39 35-44
  CrossrefPubMedGoogle Scholar
• 20 Panarai R B, Dawson S L, Eamus P J, Potter J F. Cerebral blood flow velocity response to induced and spontaneous sudden changes in arterial blood pressure.  Am J Physiol Heart Circ Physiol. 2001;  280 H 2162-H 2174
  PubMedGoogle Scholar
• 21 Pickard J D, Matheson M, Patterson J, Wyper D. Prediction of late ischemic complications after cerebral aneurysm surgery by intraoperative measurement of cerebral blood flow.  J Neurosurg. 1980;  53 305-308
  PubMedGoogle Scholar
• 22 Paulson O B, Strandgaard S, Edvinsson L. Cerebral autoregulation.  Cerebrovasc Brain Metab Rev. 1990;  2 161-192
  PubMedGoogle Scholar
• 23 Rasulo F A, Balestreri M, Matta B. Assessment of cerebral pressure autoregulation.  Current opinion in Anesthesiology. 2002;  15 483-488
  PubMedGoogle Scholar
• 24 Schmieder K, Schregel W, Harders A, Cunitz G. Dynamic cerebral autoregulation in patients undergoing surgery for intracranial tumors.  Eur J Ultrasound. 2000;  12 1-7
  CrossrefPubMedGoogle Scholar
• 25 Smielewski P, Czosnyka M, Iyer V, Piechnik S, Whitehouse H, Pickard J. Computerized transient hyperaemic response test - a method for the assessment of cerebral autoregulation.  Ultrasound Med Biol. 1995;  5 599-611
  PubMedGoogle Scholar
• 26 Steiner L A, Czosnyka M, Piechnik S K, Smielewski P, Chatfield D, Menon D, Pickard J D. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury.  Crit Care Med. 2002;  30 733-738
  CrossrefPubMedGoogle Scholar
• 27 Strebel S, Lam A M, Matta B, Mayberg T S, Aaslid R, Newell D W. Dynamic and static cerebral autoregulation during isoflurane, desflurane, and propofol anesthesia.  Anesthesiology. 1995;  83 66-76
  PubMedGoogle Scholar
• 28 Tiecks F P, Lam A M, Aaslid R. Comparison of static and dynamic cerebral autoregulation measurements.  Stroke. 1995;  26 1014-1019
  PubMedGoogle Scholar
• 29 Vavilala M S, Newell D W, Junger E, Douville C M, Aaslid R, Rivera F P, Lam A M. Dynamic cerebral autoregulation in healthy adolescents.  Acta Anaesthesiol Scand. 2002;  4 393-397
  PubMedGoogle Scholar
• 30 Voldby B, Enevoldsen E M, Jensen F T. Cerebrovascular reactivity in patients with ruptured intracranial aneurysms.  J Neurosurg. 1985;  62 59-67
  CrossrefPubMedGoogle Scholar

K. SchmiederMD 

Department of Neurosurgery · Ruhr-University Bochum

In der Schornau 23-25

44892 Bochum

Germany

Phone: +49/2 34/2 99 36 15

Fax: +49/2 34/2 99 36 09

Email: kirsten.schmieder@ruhr-uni-bochum.de