Age, intracranial pressure, autoregulation, and outcome after brain trauma

Czosnyka, Marek; Balestreri, M.; Steiner, Luzius A.; Smielewski, Peter; Hutchinson, Peter J.; Matta, Basil F.; Pickard, John D.

doi:10.3171/jns.2005.102.3.0450

Cited by 170 publications

(146 citation statements)

References 31 publications

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“…Briefly, loss of autoregulation with poor outcome may reflect the severity of TBI in patients with impaired autoregulation, or impaired cerebral autoregulation may directly impact the outcome. Not surprisingly, clinical reports of the relationship between cerebral autoregulation and outcome in both adults and children are inconsistent [2,3,[10][11][12] . Our data show that severely head-injured children with impaired autoregulation early after TBI are more likely to have a poor 6-month outcome compared with those with intact autoregulation.…”

Section: Discussionmentioning

confidence: 99%

Impaired Cerebral Autoregulation and 6-Month Outcome in Children with Severe Traumatic Brain Injury: Preliminary Findings

Vavilala

Muangman²,

Tontisirin³

et al. 2006

Dev Neurosci

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The objective of this study was to describe the incidence of impaired cerebral autoregulation and to describe the relationship between impaired cerebral autoregulation and outcome after severe pediatric traumatic brain injury (TBI). We prospectively examined cerebral autoregulation in 28 children ≤17 (10 ± 5) years with a Glasgow coma scale score <9 within the first 72 h of pediatric intensive care unit admission. Children with isolated focal TBI were excluded. Glasgow outcome scores (GOS) were collected at hospital discharge, as well as 3 and 6 months after severe TBI. GOS <4 reflected poor outcome. Cerebral autoregulation was impaired in 12/28 children. An autoregulatory index <0.4 was associated with GOS <4 at 6 months (p = 0.005). Impaired cerebral autoregulation, early after severe pediatric TBI, was associated with a poor 6-month outcome.

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Section: Discussionmentioning

confidence: 99%

Impaired Cerebral Autoregulation and 6-Month Outcome in Children with Severe Traumatic Brain Injury: Preliminary Findings

Vavilala

Muangman²,

Tontisirin³

et al. 2006

Dev Neurosci

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“…In clinical practice the conventional categorization of the severity of brain injury is primarily based on the GCS score. While the GCS represented a significant advance in the characterization of TBI, more recent studies suggest that its accuracy and prognostic power in more severely injured patients may be reduced due to effects of early sedation, neuromuscular blockade, and ventilation (Czosnyka et al, 2005;Stocchetti et al, 2004). Further, it should be realized that the commonly employed differentiation into mild (GCS score 13-15), moderate (GCS score 9-12), and severe (GCS score 8 or less) injury is artificial, and that clinical severity lies on a continuum.…”

Section: Classificationmentioning

confidence: 99%

Re-Orientation of Clinical Research in Traumatic Brain Injury: Report of an International Workshop on Comparative Effectiveness Research

Maas

Menon

Lingsma

et al. 2012

Journal of Neurotrauma

168

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During the National Neurotrauma Symposium 2010, the DG Research of the European Commission and the National Institutes of Health/National Institute of Neurological Disorders and Stroke (NIH/NINDS) organized a workshop on comparative effectiveness research (CER) in traumatic brain injury (TBI). This workshop reviewed existing approaches to improve outcomes of TBI patients. It had two main outcomes: First, it initiated a process of re-orientation of clinical research in TBI. Second, it provided ideas for a potential collaboration between the European Commission and the NIH/NINDS to stimulate research in TBI. Advances in provision of care for TBI patients have resulted from observational studies, guideline development, and meta-analyses of individual patient data. In contrast, randomized controlled trials have not led to any identifiable major advances. Rigorous protocols and tightly selected populations constrain generalizability. The workshop addressed additional research approaches, summarized the greatest unmet needs, and highlighted priorities for future research. The collection of high-quality clinical databases, associated with systems biology and CER, offers substantial opportunities. Systems biology aims to identify multiple factors contributing to a disease and addresses complex interactions. Effectiveness research aims to measure benefits and risks of systems of care and interventions in ordinary settings and broader populations. These approaches have great potential for TBI research. Although not new, they still need to be introduced to and accepted by TBI researchers as instruments for clinical research. As with therapeutic targets in individual patient management, so it is with research tools: one size does not fit all.

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“…Observations on the relationship between cerebral autoregulation and metabolism have been reported previously Reinert et al, 2007) and Chan and associates (2005) even suggested using the relationship between CPP and cerebral glutamate as a measure of autoregulatory capacity. We have used the PRx index, which has been validated against more established indices (Czosnyka et al, 1998), relates to patients' outcome (Czosnyka et al, , 2005, and has been used to estimate optimum ranges of CPP (Steiner et al, 2002). Overall comparison of metabolic parameters between preserved and deranged autoregulation, only revealing significant differences in lactate and glycerol in perilesional sites, did not suggest a substantial effect of autoregulation on energy metabolism.…”

Section: Cpp Cerebrovascular Pressure Reactivity (Prx) and Microdiamentioning

confidence: 99%

Interaction between Brain Chemistry and Physiology after Traumatic Brain Injury: Impact of Autoregulation and Microdialysis Catheter Location

Timofeev

Czosnyka

Carpenter

et al. 2011

Journal of Neurotrauma

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Bedside monitoring of cerebral metabolism in traumatic brain injury (TBI) with microdialysis is gaining wider clinical acceptance. The objective of this study was to examine the relationship between the fundamental physiological neuromonitoring modalities intracranial pressure (ICP), cerebral perfusion pressure (CPP), brain tissue oxygen (P bt O 2 ), and cerebrovascular pressure reactivity index (PRx), and cerebral chemistry assessed with microdialysis, with particular focus on the lactate/pyruvate (LP) ratio as a marker of energy metabolism. Prospectively collected observational neuromonitoring data from 97 patients with TBI, requiring neurointensive care management and invasive cerebral monitoring, were analyzed. A linear mixed model analysis was used to account for individual patient differences. Perilesional tissue chemistry exhibited a significant independent relationship with ICP, P bt O 2 and CPP thresholds, with increasing LP ratio in response to decrease in P bt O 2 and CPP, and increase in ICP. The relationship between CPP and chemistry depended upon the state of PRx. Within the studied physiological range, tissue chemistry only changed in response to increasing ICP or drop in P bt O 2 < 1.33 kPa (10 mmHg). In agreement with previous studies, significantly higher levels of cerebral lactate ( p < 0.001), glycerol ( p = 0.013), LP ratio ( p < 0.001) and lactate/glucose (LG) ratio ( p = 0.003) were found in perilesional tissue, compared to ''normal'' brain tissue (Mann-Whitney test). These differences remained significant following adjustment for the influences of other important physiological parameters (ICP, CPP, P bt O 2 , P bt CO 2 , PRx, and brain temperature; mixed linear model), suggesting that they may reflect inherent tissue properties related to the initial injury. Despite inherent biochemical differences between less-injured brain and ''perilesional'' cerebral tissue, both tissue types exhibited relationships between established physiological variables and biochemistry. Decreases in perfusion and oxygenation were associated with deteriorating neurochemistry and these effects were more pronounced in perilesional tissue and when cerebrovascular reactivity was impaired.

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Age, intracranial pressure, autoregulation, and outcome after brain trauma

Abstract: An age-related decline in cerebrovascular autoregulation was associated with a relative deterioration in outcome in elderly patients following head trauma.

Cited by 170 publications

References 31 publications

Impaired Cerebral Autoregulation and 6-Month Outcome in Children with Severe Traumatic Brain Injury: Preliminary Findings

Impaired Cerebral Autoregulation and 6-Month Outcome in Children with Severe Traumatic Brain Injury: Preliminary Findings

Re-Orientation of Clinical Research in Traumatic Brain Injury: Report of an International Workshop on Comparative Effectiveness Research

Interaction between Brain Chemistry and Physiology after Traumatic Brain Injury: Impact of Autoregulation and Microdialysis Catheter Location

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