Escalating Mean Arterial Pressure in Severe Traumatic Brain Injury: A Prospective, Observational Study

How to Define and Meet Blood Pressure Targets After Traumatic Brain Injury: A Narrative Review

BACKGROUND

Traumatic brain injury (TBI) poses a significant challenge to healthcare providers, necessitating meticulous management of hemodynamic parameters to optimize patient outcomes. This article delves into the critical task of defining and meeting continuous arterial blood pressure (ABP) and cerebral perfusion pressure (CPP) targets in the context of severe TBI in neurocritical care settings.

METHODS

We narratively reviewed existing literature, clinical guidelines, and emerging technologies to propose a comprehensive approach that integrates real-time monitoring, individualized cerebral perfusion target setting, and dynamic interventions.

RESULTS

Our findings emphasize the need for personalized hemodynamic management, considering the heterogeneity of patients with TBI and the evolving nature of their condition. We describe the latest advancements in monitoring technologies, such as autoregulation-guided ABP/CPP treatment, which enable a more nuanced understanding of cerebral perfusion dynamics. By incorporating these tools into a proactive monitoring strategy, clinicians can tailor interventions to optimize ABP/CPP and mitigate secondary brain injury.

DISCUSSION

Challenges in this field include the lack of standardized protocols for interpreting multimodal neuromonitoring data, potential variability in clinical decision-making, understanding the role of cardiac output, and the need for specialized expertise and customized software to have individualized ABP/CPP targets regularly available. The patient outcome benefit of monitoring-guided ABP/CPP target definitions still needs to be proven in patients with TBI.

CONCLUSIONS

We recommend that the TBI community take proactive steps to translate the potential benefits of personalized ABP/CPP targets, which have been implemented in certain centers, into a standardized and clinically validated reality through randomized controlled trials.

The pressure reactivity index as a measure of cerebral autoregulation and its application in traumatic brain injury management

Severe traumatic brain injury (TBI) is a major cause of morbidity and mortality globally. The Brain Trauma Foundation guidelines advocate for the maintenance of a cerebral perfusion pressure (CPP) between 60 and 70 mmHg following severe TBI. However, such a uniform goal does not account for changes in cerebral autoregulation (CA). CA refers to the complex homeostatic mechanisms by which cerebral blood flow is maintained, despite variations in mean arterial pressure and intracranial pressure. Disruption to CA has become increasingly recognised as a key mediator of secondary brain injury following severe TBI. The pressure reactivity index is calculated as the degree of statistical correlation between the slow wave components of mean arterial pressure and intracranial pressure signals and is a validated dynamic marker of CA status following brain injury. The widespread acceptance of pressure reactivity index has precipitated the consideration of individualised CPP targets or an optimal cerebral perfusion pressure (CPPopt). CPPopt represents an alternative target for cerebral haemodynamic optimisation following severe TBI, and early observational data suggest improved neurological outcomes in patients whose CPP is more proximate to CPPopt. The recent publication of a prospective randomised feasibility study of CPPopt guided therapy in TBI, suggests clinicians caring for such patients should be increasingly familiar with these concepts. In this paper, we present a narrative review of the key landmarks in the development of CPPopt and offer a summary of the evidence for CPPopt-based therapy in comparison to current standards of care.

Blood Pressure Control in Traumatic Subdural Hematomas

Background There is debate over optimal systolic blood pressure (SBP) after traumatic subdural hematoma. Increased SBP has the benefit of increasing cerebral perfusion pressure and limiting the detrimental secondary effects of traumatic brain injury but poses a risk of hematoma expansion. While prior studies have shown that SBP<90mmHg is associated with worsened morbidity and mortality in subdural hematoma patients, clinical guidelines and expert opinion have differing initial SBP goals. The aim of this study is to leverage a large database to determine the effects of two such goals, namely SBP 100-150mmHg versus SBP<180mmHg in this patient population. Methods A de-identified database network (TriNetX Research Network) was used to retrospectively query all patients with a first instance diagnosis of acute traumatic SDH, who also had a recorded GCS, with maintenance of SBP 100-150 within the first 24 hours (cohort 1) versus patients with an SBP<180 (cohort 2). Data came from 68 health care organizations (HCOs) with a total of 105,897,964 patients on 9/1/2022. The primary outcome of interest was mortality within 30 days. Secondary outcomes include gastrostomy tube placement, craniotomy/craniectomy/burr hole drainage, venous thromboembolism, ischemic stroke, myocardial infarction, seizure, falls, cardiac arrest, and acute kidney injury within 30 days. Cohorts were propensity-score matched for confounders. Results After propensity score matching, 1,243 patients were identified in each cohort. Age at index was 57.97+/-23.21 years and 58.28+/-22.35 years for cohorts 1 and 2, respectively. Mortality was seen in 243 patients (19.756%) vs. 209 (16.992%) (OR 1.203, 95% CI (0.98,1.476), p=0.0767) in cohorts 1 and 2, respectively. There was no statistical difference in secondary outcomes. Conclusion The results of this study demonstrate that the primary outcome of mortality at 30 days is not statistically different in acute traumatic SDH patients, whether their SBP is kept at 100-150 or below 180. Likewise, it shows no statistical difference in the subsequent incidence of gastrostomy tube placement, craniotomy/craniectomy/burr holes, venous thromboembolism, ischemic stroke, myocardial infarction, seizure, falls, or acute kidney injury.

The effect of extended continuous nursing strategy applied to patients with mild brain injury on their quality of life and self-efficacy

Postoperative rehabilitation of craniocerebral injury requires a long process and has many complications. In addition, patients with severe craniocerebral injury are usually accompanied by impaired nervous system function, which will affect the patients’ normal life and work in a period of time after surgery. Reasonable rehabilitation nursing plays an active role in restructuring central nervous system function and coordinating muscle and joint activities. Since the rehabilitation of cerebral trauma is a long process, how to ensure the patients to carry out limb and brain function as well as self-care ability and self-care skills according to the rehabilitation exercise plan and intervention measures formulated before discharge has aroused hot debate. This study analyzed the impact of out-of-hospital continuous nursing strategy applied to patients with mild cerebral trauma on their quality of life and self-efficacy level.

Predictive role of shock index in the early formation of cerebral infarction in patients with TBI and cerebral herniation

Background and purpose

Traumatic brain injury (TBI) with brain herniation predisposes to posttraumatic cerebral infarction (PTCI), which in turn seriously affects the prognosis of patients. At present, there is a lack of effective indicators that can accurately predict the occurrence of PTCI. We aimed to find possible risk factors for the development of PTCI by comparing the preoperative and postoperative clinical data of TBI patients with brain herniation.

Methods

The clinical data of 120 patients with craniocerebral trauma and brain herniation were retrospectively analyzed. Among them, 54 patients had cerebral infarction within 3–7 days after injury. The two groups of patients were compared through univariate and multivariate logistic regression analysis, and a classification tree model and a nomogram model were constructed. Finally, receiver operating characteristic curve analysis and decision curve analysis were conducted to analyze the clinical utility of the prediction model.

Results

Logistic regression analysis showed that factors like the Glasgow Coma Scale (GCS) score (P = 0.002), subarachnoid hemorrhage (SAH) (P = 0.005), aspiration pneumonia (P &lt; 0.001), decompressive craniectomy (P &lt; 0.05), intracranial pressure (ICP) monitoring (P = 0.006), the shock index (SI) (P &lt; 0.001), the mean arterial pressure (MAP) (P = 0.005), and blood glucose (GLU) (P &lt; 0.011) appeared to show a significant statistical correlation with the occurrence of infarction (P &lt; 0.05), while age, sex, body temperature (T), D-dimer levels, and coagulation tests were not significantly correlated with PTCI after cerebral herniation. Combined with the above factors, Classification and Regression Tree was established, and the recognition accuracy rate reached 76.67%.

Conclusions

GCS score at admission, no decompressive craniectomy, no ICP monitoring, combined SAH, combined aspiration pneumonia, SI, MAP, and high GLU were risk factors for infarction, of which SI was the primary predictor of PTCI in TBI with an area under the curve of 0.775 (95% CI = 0.689–0.861). Further large-scale studies are needed to confirm these results.

Controlled Decompression Alleviates Brain Injury via Attenuating Oxidative Damage and Neuroinflammation in Acute Intracranial Hypertension

BACKGROUND

The benefits of controlled decompression (CDC) for patients with acute intracranial hypertension especially in terms of alleviating the complications caused by rapid decompression (RDC) have been confirmed by clinical studies. This study is aimed at evaluating the therapeutic potency of CDC with ubiquitin C-terminal hydrolase-L1 (UCH-L1) and glial fibrillary acidic protein (GFAP) by investigating the potential molecular mechanism in the acute intracranial hypertension (AICH) rabbit model.

METHODS

Male New Zealand white rabbits were randomly subdivided into the sham-operated (SH) group, CDC group, and RDC group. Blood plasma samples and brain tissue were collected 2 days before operation (baseline) and at 3, 6, 24, and 72 hours after operation to measure the levels of UCH-L1, GFAP, oxidative stress indicators, and inflammatory cytokines by performing ELISA or Western blot. The neurological score of the rabbits and brain water content was graded 24 h after surgery. qPCR, immunofluorescence, and FJ-C staining were conducted.

RESULTS

CDC improved neurological function, lowered brain water content, ameliorated neuronal degeneration, attenuated oxidative damage, and inflammatory responses to a greater extent than RDC. Plasma UCH-L1 level was significantly lower in the CDC group at 3 h postoperatively than in the RDC group. CDC reduced plasma GFAP levels to various degrees at 3 h, 6 h, and 24 h postoperatively compared with RDC. Immunofluorescence confirmed that the expression of UCH-L1 and GFAP in the cortex of the CDC group was lower than that of the RDC group.

CONCLUSIONS

Our data collectively demonstrate that CDC could attenuate oxidative damage and inflammatory responses, downregulate UCH-L1 and GFAP levels, and contribute to an improved neuroprotective effect compared with RDC.