Observation of Autoregulation Indices During Ventricular CSF Drainage After Aneurysmal Subarachnoid Hemorrhage: A Pilot Study

Aries, Marcel; Jong, Sytse F. de; Dijk, J. Marc C. van; Regtien, Joost G.; Depreitere, Bart; Czosnyka, Marek; Smielewski, Peter; Elting, Jan Willem J.

doi:10.1007/s12028-015-0107-z

Cited by 22 publications

(12 citation statements)

References 23 publications

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“…Third, the validity of PRx and hence CPPopt has been questioned in case of an open EVD. However, we and others have found that ICP slow waves are preserved when the EVD is opened and PRx and CPPopt should then still be valid [ 2 , 12 ]. Fourth, the MD measured cerebral energy metabolism in a focal area in normal-appearing brain tissue in the right frontal lobe in this study.…”

Section: Discussionmentioning

confidence: 99%

Intracranial pressure- and cerebral perfusion pressure threshold-insults in relation to cerebral energy metabolism in aneurysmal subarachnoid hemorrhage

et al. 2022

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Background The aim was to investigate the association between intracranial pressure (ICP)- and cerebral perfusion pressure (CPP) threshold-insults in relation to cerebral energy metabolism and clinical outcome after aneurysmal subarachnoid hemorrhage (aSAH). Methods In this retrospective study, 75 aSAH patients treated in the neurointensive care unit, Uppsala, Sweden, 2008–2018, with ICP and cerebral microdialysis (MD) monitoring were included. The first 10 days were divided into early (day 1–3), early vasospasm (day 4–6.5), and late vasospasm phase (day 6.5–10). The monitoring time (%) of ICP insults (> 20 mmHg and > 25 mmHg), CPP insults (< 60 mmHg, < 70 mmHg, < 80 mmHg, and < 90 mmHg), and autoregulatory CPP optimum (CPPopt) insults (∆CPPopt = CPP-CPPopt < − 10 mmHg, ∆CPPopt > 10 mmHg, and within the optimal interval ∆CPPopt ± 10 mmHg) were calculated in each phase. Results Higher percent of ICP above the 20 mmHg and 25 mmHg thresholds correlated with lower MD-glucose and increased MD-lactate-pyruvate ratio (LPR), particularly in the vasospasm phases. Higher percentage of CPP below all four thresholds (60/70/80//90 mmHg) also correlated with a MD pattern of poor cerebral substrate supply (MD-LPR > 40 and MD-pyruvate < 120 µM) in the vasospasm phase and higher burden of CPP below 60 mmHg was independently associated with higher MD-LPR in the late vasospasm phase. Higher percentage of CPP deviation from CPPopt did not correlate with worse cerebral energy metabolism. Higher burden of CPP-insults below all fixed thresholds in both vasospasm phases were associated with worse clinical outcome. The percentage of ICP-insults and CPP close to CPPopt were not associated with clinical outcome. Conclusions Keeping ICP below 20 mmHg and CPP at least above 60 mmHg may improve cerebral energy metabolism and clinical outcome.

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Section: Discussionmentioning

confidence: 99%

Intracranial pressure- and cerebral perfusion pressure threshold-insults in relation to cerebral energy metabolism in aneurysmal subarachnoid hemorrhage

et al. 2022

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“…The lack of correlation between CPPopt targets and clinical outcome in aSAH patients could also be explained by that PRx and CPPopt might have a lower signal-to-noise ratio in aSAH patients that generally are treated with open EVDs. However, we and others have demonstrated that the validity of PRx and hence CPPopt is preserved when the EVD is opened [ 30 , 31 ]. Another explanation is that PRx is a global measure of pressure autoregulation, but vasospasm and DCI may be focal events [ 32 ].…”

Section: Discussionmentioning

confidence: 99%

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

et al. 2021

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Background High intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome. Methods In this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008–2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP–CPPopt) < − 10 mm Hg (%). Results Of the 242 patients, 63 (26%) had favorable (GOS-E 5–8) and 179 (74%) had unfavorable (GOS-E 1–4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5–10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups. Conclusions Avoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.

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“…The RAP index has also been shown to be an accurate measure of intracranial compliance [ 17 ]. In addition, the RAP index has been used to assess the use of extra-ventricular devices to investigate the role of cerebral auto-regulation disturbances in aneurysmal subarachnoid patients [ 18 ].…”

Section: Intracranial Pressure Indicesmentioning

confidence: 99%

The best marker for guiding the clinical management of patients with raised intracranial pressure—the RAP index or the mean pulse amplitude?

Hall

O’Kane

2016

Acta Neurochir

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Raised intracranial pressure is a common problem in a variety of neurosurgical conditions including traumatic brain injury, hydrocephalus and intracranial haemorrhage. The clinical management of these patients is guided by a variety of haemodynamic, biochemical and clinical factors. However to date there is no single parameter that is used to guide clinical management of patients with raised intracranial pressure (ICP). However, the role of ICP indices, specifically the mean pulse amplitude (AMP) and RAP index [correlation coefficient (R) between AMP amplitude (A) and mean ICP pressure (P); index of compensatory reserve], as an indicator of true ICP has been investigated. Whilst the RAP index has been used both as a descriptor of neurological deterioration in TBI patients and as a way of characterising the compensatory reserve in hydrocephalus, more recent studies have highlighted the limitation of the RAP index due to the influence that baseline effect errors have on the mean ICP, which is used in the calculation of the RAP index. These studies have suggested that the ICP mean pulse amplitude may be a more accurate marker of true intracranial pressure due to the fact that it is uninfluenced by the mean ICP and, therefore, the AMP may be a more reliable marker than the RAP index for guiding the clinical management of patients with raised ICP. Although further investigation needs to be undertaken in order to fully assess the role of ICP indices in guiding the clinical management of patients with raised ICP, the studies undertaken to date provide an insight into the potential role of ICP indices to treat raised ICP proactively rather than reactively and therefore help prevent or minimise secondary brain injury.

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Observation of Autoregulation Indices During Ventricular CSF Drainage After Aneurysmal Subarachnoid Hemorrhage: A Pilot Study

Cited by 22 publications

References 23 publications

Intracranial pressure- and cerebral perfusion pressure threshold-insults in relation to cerebral energy metabolism in aneurysmal subarachnoid hemorrhage

Intracranial pressure- and cerebral perfusion pressure threshold-insults in relation to cerebral energy metabolism in aneurysmal subarachnoid hemorrhage

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

The best marker for guiding the clinical management of patients with raised intracranial pressure—the RAP index or the mean pulse amplitude?

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