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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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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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