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Xiang T, Feng D, Zhang X, Chen Y, Wang H, Liu X, Gong Z, Yuan J, Liu M, Sha Z, Lv C, Jiang W, Nie M, Fan Y, Wu D, Dong S, Feng J, Ponomarev ED, Zhang J, Jiang R. Effects of increased intracranial pressure on cerebrospinal fluid influx, cerebral vascular hemodynamic indexes, and cerebrospinal fluid lymphatic efflux. J Cereb Blood Flow Metab 2022; 42:2287-2302. [PMID: 35962479 PMCID: PMC9670008 DOI: 10.1177/0271678x221119855] [Citation(s) in RCA: 17] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/09/2022] [Revised: 06/22/2022] [Accepted: 06/23/2022] [Indexed: 12/14/2022]
Abstract
The glymphatic-lymphatic fluid transport system (GLFTS) consists of glymphatic pathway and cerebrospinal fluid (CSF) lymphatic outflow routes, allowing biological liquids from the brain parenchyma to access the CSF along with perivascular space and to be cleaned out of the skull through lymphatic vessels. It is known that increased local pressure due to physical compression of tissue improves lymphatic transport in peripheral organs, but little is known about the exact relationship between increased intracranial pressure (IICP) and GLFTS. In this study, we verify our hypothesis that IICP significantly impacts GLFTS, and this effect depends on severity of the IICP. Using a previously developed inflating balloon model to induce IICP and inject fluorescent tracers into the cisterna magna, we found significant impairment of the glymphatic circulation after IICP. We further found that cerebrovascular occlusion occurred, and cerebrovascular pulsation decreased after IICP. IICP also interrupted the drainage of deep cervical lymph nodes and dorsal meningeal lymphatic function, enhancing spinal lymphatic outflow to the sacral lymph nodes. Notably, these effects were associated with the severity of IICP. Thus, our findings proved that the intensity of IICP significantly impacts GLFTS. This may have translational applications for preventing and treating related neurological disorders.
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Affiliation(s)
- Tangtang Xiang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Dongyi Feng
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Xinjie Zhang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Yupeng Chen
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Hanhua Wang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Xuanhui Liu
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Zhitao Gong
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Jiangyuan Yuan
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Mingqi Liu
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Zhuang Sha
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Chuanxiang Lv
- Department of Neurosurgery, The First Clinical Hospital, Jilin
University, Changchun, China
| | - Weiwei Jiang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Meng Nie
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Yibing Fan
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Di Wu
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Shiying Dong
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Jiancheng Feng
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Eugene D Ponomarev
- School of Biomedical Sciences, Faculty of Medicine, The Chinese
University of Hong Kong, Shatin, NT, Hong Kong, China
| | - Jianning Zhang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
| | - Rongcai Jiang
- Department of Neurosurgery, Tianjin Medical University General
Hospital, Tianjin, China
- Tianjin Neurological Institute, Key Laboratory of Post
Neuro-Injury Neuro-Repair and Regeneration in Central Nervous System, Ministry
of Education and Tianjin City, Tianjin, China
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Fedriga M, Czigler A, Nasr N, Zeiler FA, Park S, Donnelly J, Papaioannou V, Frisvold SK, Wolf S, Rasulo F, Sykora M, Smielewski P, Czosnyka M. Autonomic Nervous System Activity during Refractory Rise in Intracranial Pressure. J Neurotrauma 2021; 38:1662-1669. [PMID: 33280491 PMCID: PMC8336253 DOI: 10.1089/neu.2020.7091] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/13/2022] Open
Abstract
Refractory intracranial hypertension (RIH) is a dramatic increase in intracranial pressure (ICP) that cannot be controlled by treatment. Recent reports suggest that the autonomic nervous system (ANS) activity may be altered during changes in ICP. Our study aimed to assess ANS activity during RIH and the causal relationship between rising in ICP and autonomic activity. We reviewed retrospectively 24 multicenter (Cambridge, Tromso, Berlin) patients in whom RIH developed as a pre-terminal event after acute brain injury (ABI). They were monitored with ICP, arterial blood pressure (ABP), and electrocardiography (ECG) using ICM+ software. Parameters reflecting autonomic activity were computed in time and frequency domain through the measurement of heart rate variability (HRV) and baroreflex sensitivity (BRS). Our results demonstrated that a rise in ICP was associated to a significant rise in HRV and BRS with a higher significance level in the high-frequency HRV (p < 0.001). This increase was followed by a significant decrease in HRV and BRS above the upper-breakpoint of ICP where ICP pulse-amplitude starts to decrease whereas the mean ICP continues to rise. Temporality measured with a Granger test suggests a causal relationship from ICP to ANS. The above results suggest that a rise in ICP interacts with ANS activity, mainly interfacing with the parasympathetic-system. The ANS seems to react to the rise in ICP with a response possibly focused on maintaining the cerebrovascular homeostasis. This happens until the critical threshold of ICP is reached above which the ANS variables collapse, probably because of low perfusion of the brain and the central autonomic network.
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Affiliation(s)
- Marta Fedriga
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Andras Czigler
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
- Department of Neurosurgery and Szentagothai Research Center, University of Pecs, Pecs, Hungary
| | - Nathalie Nasr
- Unitè de Neurologie Vasculaire, CHU de Toulouse, Universitè de Toulouse, Toulouse, France
| | - Frederick. A. Zeiler
- Department of Surgery, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, University of Manitoba, Winnipeg, Manitoba, Canada
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Soojin Park
- Department of Neurology, Division of Hospitalist and Critical Care Neurology, Columbia University, New York, New York, USA
| | - Joseph Donnelly
- Department of Anaesthesiology, University of Auckland, Aukland, New Zealand
| | - Vasilios Papaioannou
- University Hospital of Alexandroupolis, Intensive Care Unit, Democritus University of Thrace, Alexandroupolis, Greece
| | - Shirin K Frisvold
- Department of Intensive Care, University Hospital of North Norway, UiT The Arctic University of Norway, Tromso, Norway
| | - Stephan Wolf
- Department of Neurosurgery, Charite Hospital, Berlin, Germany
| | - Frank Rasulo
- Department of Anaesthesia, Critical Care and Emergency, Spedali Civili University Hospital, Brescia, Italy
| | - Marek Sykora
- Department of Neurology, St. John's Hospital Vienna, Medical Faculty, Sigmund Freud University, Vienna, Austria
| | - Peter Smielewski
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Division of Neurosurgery, Department of Clinical Neurosciences, Physics Laboratory, University of Cambridge, Cambridge, United Kingdom
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Lalou AD, Czosnyka M, Placek MM, Smielewski P, Nabbanja E, Czosnyka Z. CSF Dynamics for Shunt Prognostication and Revision in Normal Pressure Hydrocephalus. J Clin Med 2021; 10:jcm10081711. [PMID: 33921142 PMCID: PMC8071572 DOI: 10.3390/jcm10081711] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/31/2020] [Revised: 04/09/2021] [Accepted: 04/12/2021] [Indexed: 11/16/2022] Open
Abstract
BACKGROUND Despite the quantitative information derived from testing of the CSF circulation, there is still no consensus on what the best approach could be in defining criteria for shunting and predicting response to CSF diversion in normal pressure hydrocephalus (NPH). OBJECTIVE We aimed to review the lessons learned from assessment of CSF dynamics in our center and summarize our findings to date. We have focused on reporting the objective perspective of CSF dynamics testing, without further inferences to individual patient management. DISCUSSION No single parameter from the CSF infusion study has so far been able to serve as an unquestionable outcome predictor. Resistance to CSF outflow (Rout) is an important biological marker of CSF circulation. It should not, however, be used as a single predictor for improvement after shunting. Testing of CSF dynamics provides information on hydrodynamic properties of the cerebrospinal compartment: the system which is being modified by a shunt. Our experience of nearly 30 years of studying CSF dynamics in patients requiring shunting and/or shunt revision, combined with all the recent progress made in producing evidence on the clinical utility of CSF dynamics, has led to reconsidering the relationship between CSF circulation testing and clinical improvement. CONCLUSIONS Despite many open questions and limitations, testing of CSF dynamics provides unique perspectives for the clinician. We have found value in understanding shunt function and potentially shunt response through shunt testing in vivo. In the absence of infusion tests, further methods that provide a clear description of the pre and post-shunting CSF circulation, and potentially cerebral blood flow, should be developed and adapted to the bed-space.
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Affiliation(s)
- Afroditi Despina Lalou
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Correspondence: ; Tel.: +44-774-3567-585
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
- Institute of Electronic Systems, Faculty of Electronics and Information Sciences, Warsaw University of Technology, 00-661 Warsaw, Poland
| | - Michal M. Placek
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Eva Nabbanja
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
| | - Zofia Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, University of Cambridge, Cambridge CB2 0QQ, UK; (M.C.); (M.M.P.); (P.S.); (E.N.); (Z.C.)
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Donnelly J, Zeiler FA, Güiza F, Beqiri E, Mitchell SJ, Aries MJ, Czosnyka M, Smielewski P. Visualization of Intracranial Pressure Insults After Severe Traumatic Brain Injury: Influence of Individualized Limits of Reactivity. ACTA NEUROCHIRURGICA. SUPPLEMENT 2021; 131:7-10. [PMID: 33839808 DOI: 10.1007/978-3-030-59436-7_2] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
Cerebral perfusion pressure (CPP) lower limits of reactivity can be determined almost continuously after severe traumatic brain injury (TBI), and deviation below the lower limit carries important prognostic information. In this study, we used a recently derived coloured contour method for visualizing intracranial pressure (ICP) insults to describe the influence of having a CPP above the CPP lower limits of reactivity after severe TBI. In a cohort of 729 patients, we examined the relationship between ICP insults and the 6-month Glasgow Outcome Scale score, using colour-coded plots, as described previously. We then assessed this relationship when ICP insults were above or below the CPP lower limit of reactivity. We found a curvilinear relationship whereby even prolonged durations of low-intensity ICP insults were not associated with poor outcomes but short durations of high-intensity insults were. When only ICP insults with a CPP below the CPP lower limit of reactivity were considered, a much lower intensity of ICP insults could be tolerated. A CPP above the lower limits of reactivity exerts a protective effect, whereas a CPP below the lower reactivity limits renders the patient vulnerable to increased morbidity from intracranial hypertension.
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Affiliation(s)
- Joseph Donnelly
- Academic Neurosurgery, University of Cambridge, Cambridge, UK.
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand.
| | - Frederick A Zeiler
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Division of Anaesthesia, University of Cambridge, Cambridge, UK
| | - Fabian Güiza
- Intensive Care Medicine, KU Leuven, Leuven, Belgium
| | - Erta Beqiri
- Academic Neurosurgery, University of Cambridge, Cambridge, UK
| | - Simon J Mitchell
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Marcel J Aries
- Department of Intensive Care, University of Maastricht, Maastricht, The Netherlands
| | - Marek Czosnyka
- Academic Neurosurgery, University of Cambridge, Cambridge, UK
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Froese L, Batson C, Gomez A, Dian J, Zeiler FA. The Limited Impact of Current Therapeutic Interventions on Cerebrovascular Reactivity in Traumatic Brain Injury: A Narrative Overview. Neurocrit Care 2020; 34:325-335. [PMID: 32468328 DOI: 10.1007/s12028-020-01003-4] [Citation(s) in RCA: 21] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Current intensive care unit (ICU) treatment strategies for traumatic brain injury (TBI) care focus on intracranial pressure (ICP)- and cerebral perfusion pressure (CPP)-directed therapeutics, dictated by guidelines. Impaired cerebrovascular reactivity in moderate/severe TBI is emerging as a major associate with poor outcome and appears to dominate the landscape of physiologic derangement over the course of a patient's ICU stay. Within this article, we review the literature on the known drivers of impaired cerebrovascular reactivity in adult TBI, highlight the current knowledge surrounding the impact of guideline treatment strategies on continuously monitored cerebrovascular reactivity, and discuss current treatment paradigms for impaired reactivity. Finally, we touch on the areas of future research, as we strive to develop specific therapeutics for impaired cerebrovascular reactivity in TBI. There exists limited literature to suggest advanced age, intracranial injury patterns of diffuse injury, and sustained ICP elevations may drive impaired cerebrovascular reactivity. To date, the literature suggests there is a limited impact of such ICP/CPP guideline-based therapies on cerebrovascular reactivity, with large portions of a given patients ICU period spent with impaired cerebrovascular reactivity. Emerging treatment paradigms focus on the targeting individualized CPP and ICP thresholds based on cerebrovascular reactivity, without directly targeting the pathways involved in its dysfunction. Further work involved in uncovering the molecular pathways involved in impaired cerebrovascular reactivity is required, so that we can develop therapeutics directed at its prevention and treatment.
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Affiliation(s)
- Logan Froese
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
| | - Carleen Batson
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Alwyn Gomez
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Josh Dian
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada
| | - Frederick A Zeiler
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada.
- Department of Human Anatomy and Cell Science, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB, Canada.
- Centre on Aging, University of Manitoba, Winnipeg, Canada.
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK.
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Ghoshal S, Gomez J, Sarwal A. Noninvasive ICP Monitoring by Serial Transcranial Doppler in Coagulopathic Patient. Neurocrit Care 2020; 31:216-221. [PMID: 31065876 DOI: 10.1007/s12028-019-00716-5] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/16/2022]
Affiliation(s)
| | - Jonathan Gomez
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
| | - Aarti Sarwal
- Wake Forest Baptist Medical Center, Winston-Salem, NC, USA
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Donnelly J, Smielewski P, Adams H, Zeiler FA, Cardim D, Liu X, Fedriga M, Hutchinson P, Menon DK, Czosnyka M. Observations on the Cerebral Effects of Refractory Intracranial Hypertension After Severe Traumatic Brain Injury. Neurocrit Care 2020; 32:437-447. [PMID: 31240622 PMCID: PMC7082389 DOI: 10.1007/s12028-019-00748-x] [Citation(s) in RCA: 15] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023]
Abstract
BACKGROUND Raised intracranial pressure (ICP) is a prominent cause of morbidity and mortality after severe traumatic brain injury (TBI). However, in the clinical setting, little is known about the cerebral physiological response to severe and prolonged increases in ICP. METHODS Thirty-three severe TBI patients from a single center who developed severe refractory intracranial hypertension (ICP > 40 mm Hg for longer than 1 h) with ICP, arterial blood pressure, and brain tissue oxygenation (PBTO2) monitoring (subcohort, n = 9) were selected for retrospective review. Secondary parameters reflecting autoregulation (including pressure reactivity index-PRx, which was available in 24 cases), cerebrospinal compensatory reserve (RAP), and ICP pulse amplitude were calculated. RESULTS PRx deteriorated from 0.06 ± 0.26 a.u. at baseline levels of ICP to 0.57 ± 0.24 a.u. (p < 0.0001) at high levels of ICP (> 50 mm Hg). In 4 cases, PRx was impaired (> 0.25 a.u.) before ICP was raised above 25 mm Hg. Concurrently, PBTO2 decreased from 27.3 ± 7.32 mm Hg at baseline ICP to 12.68 ± 7.09 mm Hg at high levels of ICP (p < 0.001). The pulse amplitude of the ICP waveform increased with increasing ICP but showed an 'upper breakpoint'-whereby further increases in ICP lead to decreases in pulse amplitude-in 6 out of the 33 patients. DISCUSSION Severe intracranial hypertension after TBI leads to decreased brain oxygenation, impaired pressure reactivity, and changes in the pulse amplitude of ICP. Impaired pressure reactivity may denote increased risk of developing refractory intracranial hypertension in some patients.
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Affiliation(s)
- Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK.
- Department of Anaesthesiology, Level 12 Auckland Support Building, Auckland City Hospital, University of Auckland, 2 Park Road, Grafton, Auckland, New Zealand.
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Hadie Adams
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Frederick A Zeiler
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Biomedical Engineering, Faculty of Engineering, University of Manitoba, Winnipeg, Canada
- Department of Human Anatomy and Cell Sciences, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Danilo Cardim
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Xiuyun Liu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Marta Fedriga
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Peter Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, Addenbrooke's Hospital, University of Cambridge, Cambridge, UK
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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Cerebral Blood Flow in Low Intracranial Pressure Headaches-What is Known? Brain Sci 2019; 10:brainsci10010002. [PMID: 31861526 PMCID: PMC7016724 DOI: 10.3390/brainsci10010002] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/19/2019] [Revised: 12/14/2019] [Accepted: 12/16/2019] [Indexed: 12/22/2022] Open
Abstract
Headaches attributed to low cerebrospinal fluid (CSF) pressure are described as orthostatic headaches caused by spontaneous or secondary low CSF pressure or CSF leakages. Regardless of the cause, CFS leaks may lead to intracranial hypotension (IH) and influence cerebral blood flow (CBF). When CSF volume decreases, a compensative increase in intracranial blood volume and cerebral vasodilatation occurs. Sinking of the brain and traction on pain-sensitive structures are thought to be the causes of orthostatic headaches. Although there are many studies concerning CBF during intracranial hypertension, little is known about CBF characteristics during low intracranial pressure. The aim of this review is to examine the relationship between CBF, CSF, and intracranial pressure in headaches assigned to low CSF pressure.
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Using computerized tomography perfusion to measure cerebral hemodynamics following treatment of traumatic brain injury in rabbits. Exp Ther Med 2019; 18:2104-2110. [PMID: 31410165 PMCID: PMC6676178 DOI: 10.3892/etm.2019.7785] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/01/2018] [Accepted: 05/16/2019] [Indexed: 11/09/2022] Open
Abstract
The present study aimed to investigate the use of computerized tomography (CT) perfusion for evaluating cerebral hemodynamics following traumatic brain injury (TBI) in rabbits. The animals were randomly assigned into four groups (n=10 animals/group): i) Control, ii) TBI, iii) TBI + common decompression and iv) TBI + controlled decompression groups. A TBI model was established in rabbits using epidural balloon inflation. In the groups receiving intervention, animals were provided common decompression or controlled decompression treatments. Conventional CT and CT perfusion scanning were performed, with cerebral hemodynamic indices, including regional cerebral blood flow (rCBF), regional cerebral blood volume (rCBV) and mean transit time (MTT) being measured. Blood-brain barrier (BBB) permeability was evaluated using Evans blue staining. Compared with those in the control group, rCBF and rCBV values of the bilateral temporal lobes and basal ganglion in the TBI, TBI + common decompression and TBI + controlled decompression groups were significantly lower, whereas the MTT values were markedly prolonged and Evans blue dye content was greatly increased (P<0.01). Controlled decompression was demonstrated to be more potent than common decompression for preventing TBI-induced decline in rCBF and rCBV values in the bilateral temporal lobes and basal ganglion, as well as reversing TBI-induced extension of MTT in the bilateral temporal lobes (P<0.01 vs. TBI group). However, neither common nor controlled decompression could reduce TBI-induced increase in BBB permeability. In conclusion, these findings indicate that CT perfusion may be used to monitor cerebral hemodynamics following TBI in rabbits. Controlled decompression was deduced to be more potent than common decompression for preventing abnormalities in cerebral hemodynamics after TBI.
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Gao Y, Li Q, Wu C, Liu S, Zhang M. Use of a Doppler-Based Pulsatility Index to Evaluate Cerebral Hemodynamics in Neurocritical Patients After Hemicraniectomy. JOURNAL OF ULTRASOUND IN MEDICINE : OFFICIAL JOURNAL OF THE AMERICAN INSTITUTE OF ULTRASOUND IN MEDICINE 2019; 38:2469-2475. [PMID: 30697782 PMCID: PMC6850122 DOI: 10.1002/jum.14945] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 07/04/2018] [Revised: 12/07/2018] [Accepted: 01/03/2019] [Indexed: 06/09/2023]
Abstract
OBJECTIVES As a noninvasive method for evaluation of cerebral hemodynamics, the correct interpretation of transcranial Doppler or transcranial imaging (TCI) data remains a major challenge. We explored how to interpret the pulsatility index (PI) derived via TCI during evaluations of cerebral hemodynamics in posthemicraniectomy patients. METHODS We included patients who underwent invasive arterial pressure and intracranial pressure (ICP) monitoring and simultaneous TCI examinations after hemicraniectomy. We classified the PI of the middle cerebral artery (MCA) into ipsilateral (craniectomy side) and contralateral (opposite side) and analyzed both data sets. The statistical analysis was performed by the Bland-Altman approach, by calculating intraclass correlation coefficients and Spearman correlations, and by drawing receiver operating characteristic curves. Pulsatility index probability charts were created for ICPs exceeding 20, 25, and 30 mm Hg and cerebral perfusion pressures (CPPs) lower than 70, 60, and 50 mm Hg; we thus explored defined ICP and CPP values. RESULTS The ipsilateral and contralateral MCA PI data differed. Only the ipsilateral MCA PI showed a weak correlation with ICP (r = 0.378; P < .001). The receiver operating characteristic curve analysis revealed limited diagnostic utility of bilateral MCA PIs for ICP and CPP assessments. An extremely elevated MCA PI indicated that patients were at high risk of a dangerous ICP elevation or CPP reduction. However, MCA PI values within the normal range did not effectively rule out an ICP of 20 mm Hg or higher but effectively eliminated a CPP lower than 50 mm Hg. CONCLUSIONS In posthemicraniectomy patients, the Doppler-based MCA PI value was ineffectively for quantitative ICP and CPP evaluations but a useful index for assessment of cerebral hemodynamics in terms of the probability of an ICP elevation or a CPP reduction.
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Affiliation(s)
- Yu‐zhi Gao
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Qiang Li
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Chun‐shuang Wu
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Shao‐yun Liu
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
| | - Mao Zhang
- Department of Emergency MedicineSecond Affiliated Hospital, Zhejiang University School of MedicineHangzhouChina
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11
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Zeiler FA, Kim DJ, Cabeleira M, Calviello L, Smielewski P, Czosnyka M. Impaired cerebral compensatory reserve is associated with admission imaging characteristics of diffuse insult in traumatic brain injury. Acta Neurochir (Wien) 2018; 160:2277-2287. [PMID: 30251196 PMCID: PMC6267721 DOI: 10.1007/s00701-018-3681-y] [Citation(s) in RCA: 13] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/14/2018] [Accepted: 09/17/2018] [Indexed: 12/14/2022]
Abstract
Background Continuous assessment of cerebral compensatory reserve is possible using the moving correlation between pulse amplitude of intra-cranial pressure (AMP) and intra-cranial pressure (ICP), called RAP. Little is known about the behavior and associations of this index in adult traumatic brain injury (TBI). The goal of this study is to evaluate the association between admission cerebral imaging findings and RAP over the course of the acute intensive care unit stay. Methods We retrospectively reviewed 358 adult TBI patients admitted to the Addenbrooke’s Hospital, University of Cambridge, from March 2005 to December 2016. Only non-craniectomy patients were studied. Using archived high frequency physiologic signals, RAP was derived and analyzed over the first 48 h and first 10 days of recording in each patient, using grand mean, percentage of time above various thresholds, and integrated area under the curve (AUC) of RAP over time. Associations between these values and admission computed tomography (CT) injury characteristics were evaluated. Results The integrated AUC, based on various thresholds of RAP, was statistically associated with admission CT markers of diffuse TBI and cerebral edema. Admission CT findings of cortical gyral effacement, lateral ventricle compression, diffuse cortical subarachnoid hemorrhage (SAH), thickness of cortical SAH, presence of bilateral contusions, and subcortical diffuse axonal injury (DAI) were all associated with AUC of RAP over time. Joncheere-Terpstra testing indicated a statistically significant increase in mean RAP AUC across ordinal categories of the abovementioned associated CT findings. Conclusions RAP is associated with cerebral CT injury patterns of diffuse injury and edema, providing some confirmation of its potential measurement of cerebral compensatory reserve in TBI. Electronic supplementary material The online version of this article (10.1007/s00701-018-3681-y) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Section of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, MB Canada
- Clinician Investigator Program, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Canada
| | - Dong-Joo Kim
- Department of Brain and Cognitive Engineering, Korea University, Seoul, South Korea
| | - Manuel Cabeleira
- Section of Brain Physics, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Leanne Calviello
- Section of Brain Physics, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Peter Smielewski
- Section of Brain Physics, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ UK
| | - Marek Czosnyka
- Section of Brain Physics, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, CB2 0QQ UK
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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12
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Donnelly J, Czosnyka M, Adams H, Cardim D, Kolias AG, Zeiler FA, Lavinio A, Aries M, Robba C, Smielewski P, Hutchinson PJA, Menon DK, Pickard JD, Budohoski KP. Twenty-Five Years of Intracranial Pressure Monitoring After Severe Traumatic Brain Injury: A Retrospective, Single-Center Analysis. Neurosurgery 2018; 85:E75-E82. [DOI: 10.1093/neuros/nyy468] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/16/2018] [Accepted: 09/11/2018] [Indexed: 12/20/2022] Open
Abstract
Abstract
BACKGROUND
Intracranial pressure (ICP) is a clinically important variable after severe traumatic brain injury (TBI) and has been monitored, along with clinical outcome, for over 25 yr in Addenbrooke's hospital, Cambridge, United Kingdom. This time period has also seen changes in management strategies with the implementation of protocolled specialist neurocritical care, expansion of neuromonitoring techniques, and adjustments of clinical treatment targets.
OBJECTIVE
To describe the changes in intracranial monitoring variables over the past 25 yr.
METHODS
Data from 1146 TBI patients requiring ICP monitoring were analyzed. Monitored variables included ICP, cerebral perfusion pressure (CPP), and the cerebral pressure reactivity index (PRx). Data were stratified into 5-yr epochs spanning the 25 yr from 1992 to 2017.
RESULTS
CPP increased sharply with specialist neurocritical care management (P < 0.0001) (introduction of a specific TBI management algorithm) before stabilizing from 2000 onwards. ICP decreased significantly over the 25 yr of monitoring from an average of 19 to 12 mmHg (P < 0.0001) but PRx remained unchanged. The mean number of ICP plateau waves and the number of patients developing refractory intracranial hypertension both decreased significantly. Mortality did not significantly change in the cohort (22%).
CONCLUSION
We demonstrate the evolving trends in neurophysiological monitoring over the past 25 yr from a single, academic neurocritical care unit. ICP and CPP were responsive to the introduction of an ICP/CPP protocol while PRx has remained unchanged.
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Affiliation(s)
- Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesiology, University of Auckland, Auckland, New Zealand
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
| | - Hadie Adams
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Anesthesiology, Pharmacology and Therapeutics, Vancouver General Hospital, University of British Columbia, Vancouver, Canada
| | - Angelos G Kolias
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
| | - Frederick A Zeiler
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
| | - Andrea Lavinio
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - Marcel Aries
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, Netherlands
| | - Chiara Robba
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
- Department of Anaesthesia and Intensive Care, Policlinico San Martino, IRCCS for Oncology, University of Genoa, Genoa, Italy
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J A Hutchinson
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K Menon
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Anaesthesia, Department of Medicine, University of Cambridge, Cambridge, United Kingdom
| | - John D Pickard
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Karol P Budohoski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- NIHR Global Health Research Group on Neurotrauma, University of Cambridge, Cambridge, United Kingdom
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
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13
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Zeiler FA, Donnelly J, Calviello L, Lee JK, Smielewski P, Brady K, Kim DJ, Czosnyka M. Validation of Pressure Reactivity and Pulse Amplitude Indices against the Lower Limit of Autoregulation, Part I: Experimental Intracranial Hypertension. J Neurotrauma 2018; 35:2803-2811. [PMID: 29978744 DOI: 10.1089/neu.2017.5603] [Citation(s) in RCA: 36] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
The purpose of this study was to provide validation of intracranial pressure (ICP) derived continuous indices of cerebrovascular reactivity against the lower limit of autoregulation (LLA). Utilizing an intracranial hypertension model within white New Zealand rabbits, ICP, transcranial Doppler (TCD), laser Doppler flowmetry (LDF), and arterial blood pressure were recorded. Data were retrospectively analyzed in a cohort of 12 rabbits with adequate signals for interrogating the LLA. We derived continuous indices of cerebrovascular reactivity: PRx (correlation between ICP and mean arterial pressure [MAP]), PAx (correlation between pulse amplitude of ICP [AMP] and MAP), and Lx (correlation between LDF-based cerebral blood flow [CBF] and cerebral perfusion pressure [CPP]). LLA was derived via piecewise linear regression of CPP versus LDF or CPP versus systolic flow velocity (FVs) plots. We then produced error bar plots for PRx, PAx, and Lx against 2.5 mm Hg bins of CPP, to display the relationship between these indices and the LLA. We compared the CPP values at clinically relevant thresholds of PRx and PAx, to the CPP defined at the LLA. Receiver operating curve (ROC) analysis was performed for each index across the LLA using 2.5 mm Hg bins for CPP. The mean LLA was 51.5 ± 8.2 mm Hg. PRx and PAx error bar plots demonstrate that each index correlates with the LLA, becoming progressively more positive below the LLA. Similarly, CPP values at clinically relevant thresholds of PRx and PAx were not statistically different from the CPP derived at the LLA. Finally, ROC analysis indicated that PRx and PAx predicted the LAA, with areas under the curve (AUCs) of 0.795 (95% confidence interval [CI]: 0.731-0.857, p < 0.0001) and 0.703 (95% CI: 0.631-0.775, p < 0.0001), respectively. Both PRx and PAx generally agree with LLA within this experimental model of intracranial hypertension. Further analysis of clinically used indices of autoregulation across the LLA within pure arterial hypotension models is required.
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Affiliation(s)
- Frederick A Zeiler
- 1 Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
- 2 Section of Surgery, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Canada
- 3 Clinician Investigator Program, Rady Faculty of Health Sciences, University of Manitoba , Winnipeg, Canada
| | - Joseph Donnelly
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Leanne Calviello
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Jennifer K Lee
- 5 Department of Anesthesiology and Critical Care Medicine, Johns Hopkins , Baltimore, Maryland
| | - Peter Smielewski
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
| | - Ken Brady
- 6 Pediatric Cardiology, Texas Children's Hospital , Baylor College of Medicine, Houston, Texas
| | - Dong-Joo Kim
- 7 Department of Brain and Cognitive Engineering, Korea University , Seoul, South Korea
| | - Marek Czosnyka
- 4 Section of Brain Physics, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge , Cambridge, United Kingdom
- 8 Institute of Electronic Systems, Warsaw University of Technology , Warsaw, Poland
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14
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Calviello LA, de Riva N, Donnelly J, Czosnyka M, Smielewski P, Menon DK, Zeiler FA. Relationship Between Brain Pulsatility and Cerebral Perfusion Pressure: Replicated Validation Using Different Drivers of CPP Change. Neurocrit Care 2018; 27:392-400. [PMID: 28547321 PMCID: PMC5700211 DOI: 10.1007/s12028-017-0404-9] [Citation(s) in RCA: 15] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/31/2023]
Abstract
Background Determination of relationships between transcranial Doppler (TCD)-based spectral pulsatility index (sPI) and pulse amplitude (AMP) of intracranial pressure (ICP) in 2 groups of severe traumatic brain injury (TBI) patients (a) displaying plateau waves and (b) with unstable mean arterial pressure (MAP). Methods We retrospectively reviewed patients with severe TBI and continuous TCD monitoring displaying either plateau waves or unstable MAP from 1992 to 1998. We utilized linear and nonlinear regression techniques to describe both cohorts: cerebral perfusion pressure (CPP) versus AMP, CPP versus sPI, mean ICP versus ICP AMP, mean ICP versus sPI, and AMP versus sPI. Results Nonlinear regression techniques were employed to analyze the relationships with CPP. In plateau wave and unstable MAP patients, CPP versus sPI displayed an inverse nonlinear relationship (R2 = 0.820 vs. R2 = 0.610, respectively), with the CPP versus sPI relationship best modeled by the following function in both cases: PI = a + (b/CPP). Similarly, in both groups, CPP versus AMP displayed an inverse nonlinear relationship (R2 = 0.610 vs. R2 = 0.360, respectively). Positive linear correlations were displayed in both the plateau wave and unstable MAP cohorts between: ICP versus AMP, ICP versus sPI, AMP versus sPI. Conclusions There is an inverse relationship through nonlinear regression between CPP versus AMP and CPP versus sPI display. This provides evidence to support a previously-proposed model of TCD pulsatility index. ICP shows a positive linear correlation with AMP and sPI, which is also established between AMP and sPI. Electronic supplementary material The online version of this article (doi:10.1007/s12028-017-0404-9) contains supplementary material, which is available to authorized users.
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Affiliation(s)
- Leanne A. Calviello
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Nicolás de Riva
- Division of Neuroanesthesia, Department of Anesthesiology, Hospital Clinic, Universitat de Barcelona, Barcelona, Spain
| | - Joseph Donnelly
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Peter Smielewski
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - David K. Menon
- Division of Anesthetics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Neurosciences Critical Care Unit, Addenbrooke’s Hospital, Cambridge, UK
- Queens’ College, Cambridge, UK
- National Institute for Health Research, Cambridge, UK
| | - Frederick A. Zeiler
- Division of Anesthetics, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Section of Neurosurgery, Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Canada
- Clinician Investigator Program, University of Manitoba, Winnipeg, Canada
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15
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Abstract
OBJECTIVES Increased intracranial pressure (ICP) is a pathological feature of many neurological diseases; however, the local and systemic sequelae of raised ICP are incompletely understood. Using an experimental paradigm, we aimed to describe the cerebrovascular consequences of acute increases in ICP. MATERIALS AND METHODS We assessed cerebral haemodynamics [mean arterial blood pressure (MAP), ICP, laser Doppler flowmetry (LDF), basilar artery Doppler flow velocity (Fv) and estimated vascular wall tension (WT)] in 27 basilar artery-dependent rabbits during experimental (artificial lumbar CSF infusion) intracranial hypertension. WT was estimated as the difference between critical closing pressure and ICP. RESULTS From baseline (~9 mmHg) to moderate increases in ICP (~41 mmHg), cortical LDF decreased (from 100 to 39.1%, p < 0.001), while mean global Fv was unchanged (from 47 to 45 cm/s, p = 0.38). In addition, MAP increased (from 88.8 to 94.2 mmHg, p < 0.01 and WT decreased (from 19.3 to 9.8 mmHg, p < 0.001). From moderate to high ICP (~75 mmHg), both global Fv and cortical LDF decreased (Fv, from 45 to 31.3 cm/s, p < 0.001; LDF, from 39.1 to 13.3%, p < 0.001) while MAP increased further (94.2 to 114.5 mmHg, p < 0.001) and estimated WT was unchanged (from 9.7 to 9.6 mmHg, p = 0.35). CONCLUSION In this analysis, we demonstrate a cortical vulnerability to increases in ICP and two ICP-dependent cerebro-protective mechanisms: with moderate increases in ICP, WT decreases and MAP increases to buffer cerebral perfusion, while with severe increases of ICP, an increased MAP predominates.
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16
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Zeiler FA, Donnelly J, Menon DK, Smielewski P, Hutchinson PJ, Czosnyka M. A Description of a New Continuous Physiological Index in Traumatic Brain Injury Using the Correlation between Pulse Amplitude of Intracranial Pressure and Cerebral Perfusion Pressure. J Neurotrauma 2018; 35:963-974. [DOI: 10.1089/neu.2017.5241] [Citation(s) in RCA: 33] [Impact Index Per Article: 5.5] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/12/2022] Open
Affiliation(s)
- Frederick A. Zeiler
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Department of Surgery, Rady Faculty of Health Sciences, University of Manitoba, Winnipeg, Manitoba, Canada
- Clinician Investigator Program, Rady Faculty of Health Science, University of Manitoba, Winnipeg, Manitoba, Canada
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - David K. Menon
- Division of Anaesthesia, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Peter J.A. Hutchinson
- Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Addenbrooke's Hospital, University of Cambridge, Cambridge, United Kingdom
- Institute of Electronic Systems, Warsaw University of Technology, Warsaw, Poland
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17
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Schmidt EA, Despas F, Pavy-Le Traon A, Czosnyka Z, Pickard JD, Rahmouni K, Pathak A, Senard JM. Intracranial Pressure Is a Determinant of Sympathetic Activity. Front Physiol 2018; 9:11. [PMID: 29472865 PMCID: PMC5809772 DOI: 10.3389/fphys.2018.00011] [Citation(s) in RCA: 65] [Impact Index Per Article: 10.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/03/2017] [Accepted: 01/05/2018] [Indexed: 11/17/2022] Open
Abstract
Intracranial pressure (ICP) is the pressure within the cranium. ICP rise compresses brain vessels and reduces cerebral blood delivery. Massive ICP rise leads to cerebral ischemia, but it is also known to produce hypertension, bradycardia and respiratory irregularities due to a sympatho-adrenal mechanism termed Cushing response. One still unresolved question is whether the Cushing response is a non-synaptic acute brainstem ischemic mechanism or part of a larger physiological reflex for arterial blood pressure control and homeostasis regulation. We hypothesize that changes in ICP modulates sympathetic activity. Thus, modest ICP increase and decrease were achieved in mice and patients with respectively intra-ventricular and lumbar fluid infusion. Sympathetic activity was gauged directly by microneurography, recording renal sympathetic nerve activity in mice and muscle sympathetic nerve activity in patients, and gauged indirectly in both species by heart-rate variability analysis. In mice (n = 15), renal sympathetic activity increased from 29.9 ± 4.0 bursts.s−1 (baseline ICP 6.6 ± 0.7 mmHg) to 45.7 ± 6.4 bursts.s−1 (plateau ICP 38.6 ± 1.0 mmHg) and decreased to 34.8 ± 5.6 bursts.s−1 (post-infusion ICP 9.1 ± 0.8 mmHg). In patients (n = 10), muscle sympathetic activity increased from 51.2 ± 2.5 bursts.min−1 (baseline ICP 8.3 ± 1.0 mmHg) to 66.7 ± 2.9 bursts.min−1 (plateau ICP 25 ± 0.3 mmHg) and decreased to 58.8 ± 2.6 bursts.min−1 (post-infusion ICP 14.8 ± 0.9 mmHg). In patients 7 mmHg ICP rise significantly increases sympathetic activity by 17%. Heart-rate variability analysis demonstrated a significant vagal withdrawal during the ICP rise, in accordance with the microneurography findings. Mice and human results are alike. We demonstrate in animal and human that ICP is a reversible determinant of efferent sympathetic outflow, even at relatively low ICP levels. ICP is a biophysical stress related to the forces within the brain. But ICP has also to be considered as a physiological stressor, driving sympathetic activity. The results suggest a novel physiological ICP-mediated sympathetic modulation circuit and the existence of a possible intracranial (i.e., central) baroreflex. Modest ICP rise might participate to the pathophysiology of cardio-metabolic homeostasis imbalance with sympathetic over-activity, and to the pathogenesis of sympathetically-driven diseases.
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Affiliation(s)
- Eric A Schmidt
- Institut des Maladies Métaboliques et Cardiovasculaires, I2MC, Institut National de la Santé et de la Recherche Médicale, Université de Toulouse, Toulouse, France.,Department of Neurosurgery, University Hospital of Toulouse, Toulouse, France
| | - Fabien Despas
- Institut des Maladies Métaboliques et Cardiovasculaires, I2MC, Institut National de la Santé et de la Recherche Médicale, Université de Toulouse, Toulouse, France.,Department of Clinical Pharmacology, University Hospital of Toulouse, Toulouse, France
| | - Anne Pavy-Le Traon
- Institut des Maladies Métaboliques et Cardiovasculaires, I2MC, Institut National de la Santé et de la Recherche Médicale, Université de Toulouse, Toulouse, France.,Department of Neurology, University Hospital of Toulouse, Toulouse, France
| | - Zofia Czosnyka
- Brain Physics Lab, Academic Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - John D Pickard
- Brain Physics Lab, Academic Neurosurgery, University of Cambridge, Cambridge, United Kingdom
| | - Kamal Rahmouni
- Departments of Pharmacology, University of Iowa, Iowa City, IA, United States
| | - Atul Pathak
- Institut des Maladies Métaboliques et Cardiovasculaires, I2MC, Institut National de la Santé et de la Recherche Médicale, Université de Toulouse, Toulouse, France.,Department of Clinical Pharmacology, University Hospital of Toulouse, Toulouse, France
| | - Jean M Senard
- Institut des Maladies Métaboliques et Cardiovasculaires, I2MC, Institut National de la Santé et de la Recherche Médicale, Université de Toulouse, Toulouse, France.,Department of Clinical Pharmacology, University Hospital of Toulouse, Toulouse, France
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Calviello L, Donnelly J, Cardim D, Robba C, Zeiler FA, Smielewski P, Czosnyka M. Compensatory-Reserve-Weighted Intracranial Pressure and Its Association with Outcome After Traumatic Brain Injury. Neurocrit Care 2017; 28:212-220. [DOI: 10.1007/s12028-017-0475-7] [Citation(s) in RCA: 25] [Impact Index Per Article: 3.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/25/2022]
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19
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Donnelly J, Czosnyka M, Adams H, Robba C, Steiner LA, Cardim D, Cabella B, Liu X, Ercole A, Hutchinson PJ, Menon DK, Aries MJH, Smielewski P. Individualizing Thresholds of Cerebral Perfusion Pressure Using Estimated Limits of Autoregulation. Crit Care Med 2017; 45:1464-1471. [PMID: 28816837 PMCID: PMC5595234 DOI: 10.1097/ccm.0000000000002575] [Citation(s) in RCA: 102] [Impact Index Per Article: 14.6] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/14/2022]
Abstract
OBJECTIVES In severe traumatic brain injury, cerebral perfusion pressure management based on cerebrovascular pressure reactivity index has the potential to provide a personalized treatment target to improve patient outcomes. So far, the methods have focused on identifying "one" autoregulation-guided cerebral perfusion pressure target-called "cerebral perfusion pressure optimal". We investigated whether a cerebral perfusion pressure autoregulation range-which uses a continuous estimation of the "lower" and "upper" cerebral perfusion pressure limits of cerebrovascular pressure autoregulation (assessed with pressure reactivity index)-has prognostic value. DESIGN Single-center retrospective analysis of prospectively collected data. SETTING The neurocritical care unit at a tertiary academic medical center. PATIENTS Data from 729 severe traumatic brain injury patients admitted between 1996 and 2016 were used. Treatment was guided by controlling intracranial pressure and cerebral perfusion pressure according to a local protocol. INTERVENTIONS None. METHODS AND MAIN RESULTS Cerebral perfusion pressure-pressure reactivity index curves were fitted automatically using a previously published curve-fitting heuristic from the relationship between pressure reactivity index and cerebral perfusion pressure. The cerebral perfusion pressure values at which this "U-shaped curve" crossed the fixed threshold from intact to impaired pressure reactivity (pressure reactivity index = 0.3) were denoted automatically the "lower" and "upper" cerebral perfusion pressure limits of reactivity, respectively. The percentage of time with cerebral perfusion pressure below (%cerebral perfusion pressure < lower limit of reactivity), above (%cerebral perfusion pressure > upper limit of reactivity), or within these reactivity limits (%cerebral perfusion pressure within limits of reactivity) was calculated for each patient and compared across dichotomized Glasgow Outcome Scores. After adjusting for age, initial Glasgow Coma Scale, and mean intracranial pressure, percentage of time with cerebral perfusion pressure less than lower limit of reactivity was associated with unfavorable outcome (odds ratio %cerebral perfusion pressure < lower limit of reactivity, 1.04; 95% CI, 1.02-1.06; p < 0.001) and mortality (odds ratio, 1.06; 95% CI, 1.04-1.08; p < 0.001). CONCLUSIONS Individualized autoregulation-guided cerebral perfusion pressure management may be a plausible alternative to fixed cerebral perfusion pressure threshold management in severe traumatic brain injury patients. Prospective randomized research will help define which autoregulation-guided method is beneficial, safe, and most practical.
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Affiliation(s)
- Joseph Donnelly
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Marek Czosnyka
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
- Institute of Electronic Systems, Warsaw University of Technology, Poland
| | - Hadie Adams
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Chiara Robba
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
- Department of Neuroscience, University of Genoa, Italy
| | - Luzius A Steiner
- Department for Anesthesia, Surgical Intensive Care, Prehospital Emergency Medicine and Pain Therapy, University Hospital Basel, University of Basel Switzerland
| | - Danilo Cardim
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Brenno Cabella
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Xiuyun Liu
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
| | - Ari Ercole
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Peter J Hutchinson
- Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - David K Menon
- Division of Anaesthesia, Department of Medicine, Addenbrooke’s Hospital, University of Cambridge, Cambridge, UK
| | - Marcel JH Aries
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
- Department of Intensive Care, University of Maastricht, Maastricht University Medical Center, Maastricht, The Netherlands
| | - Peter Smielewski
- Brain Physics Laboratory, Division of Neurosurgery, Department of Clinical Neurosciences, Cambridge Biomedical Campus, University of Cambridge, Cambridge, UK
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