Advertisement

Neurocritical Care

, Volume 15, Issue 3, pp 379–386 | Cite as

Pulsatile Intracranial Pressure and Cerebral Autoregulation After Traumatic Brain Injury

  • D. K. RadolovichEmail author
  • M. J. H. Aries
  • G. Castellani
  • A. Corona
  • A. Lavinio
  • P. Smielewski
  • J. D. Pickard
  • M. Czosnyka
Original Article

Abstract

Background

Strong correlation between mean intracranial pressure (ICP) and its pulse wave amplitude (AMP) has been demonstrated in different clinical scenarios. We investigated the relationship between invasive mean arterial blood pressure (ABP) and AMP to explore its potential role as a descriptor of cerebrovascular pressure reactivity after traumatic brain injury (TBI).

Methods

We retrospectively analyzed data of patients suffering from TBI with brain monitoring. Transcranial Doppler blood flow velocity, ABP, ICP were recorded digitally. Cerebral perfusion pressure (CPP) and AMP were derived. A new index—pressure-amplitude index (PAx)—was calculated as the Pearson correlation between (averaged over 10 s intervals) ABP and AMP with a 5 min long moving average window. The previously introduced transcranial Doppler-based autoregulation index Mx was evaluated in a similar way, as the moving correlation between blood flow velocity and CPP. The clinical outcome was assessed after 6 months using the Glasgow outcome score.

Results

293 patients were studied. The mean PAx was −0.09 (standard deviation 0.21). This negative value indicates that, on average, an increase in ABP causes a decrease in AMP and vice versa. PAx correlated strong with Mx (R 2 = 0.46, P < 0.0002). PAx also correlated with age (R 2 = 0.18, P < 0.05). PAx was found to have as good predictive outcome value (area under curve 0.71, P < 0.001) as Mx (area under curve 0.69, P < 0.001).

Conclusions

We demonstrated significant correlation between the known cerebral autoregulation index Mx and PAx. This new index of cerebrovascular pressure reactivity using ICP pulse wave information showed to have a strong association with outcome in TBI patients.

Keywords

Traumatic brain injury Intracranial pressure amplitude Flow velocity waveform analysis Cerebrovascular autoregulation 

Notes

Acknowledgments

The project was supported by the National Institute of Health Research, Biomedical Research Centre, Cambridge University Hospital Foundation Trust – Neurosciences Theme (MC, PS) and Senior Investigator Awards (JDP). MJH Aries received a travel grant from the European Federation of Neurological Societies (EFNS) and is supported by the Netherlands Organisation for Health Research and Development. ICM+ is licensed by University of Cambridge, Cambridge Enterprise Ltd.

Conflict of interest

MC and PS have financial interest in a fraction of licensing fee.

References

  1. 1.
    Bratton SL, Chestnut RM, Ghajar J, et al. Guidelines for the management of severe traumatic brain injury. VIII. Intracranial pressure thresholds. J Neurotrauma. 2007;24(Suppl 1):S55–8.PubMedGoogle Scholar
  2. 2.
    Guillaume J, Janny P. Continuous intracranial manometry; importance of the method, first results. Rev Neurol (Paris). 1951;84(2):131–42.Google Scholar
  3. 3.
    Lundberg N. Continuous recording and control of ventricular fluid pressure in neurosurgical practice. Acta Psychiatr Scand Suppl. 1960;36(149):1–193.PubMedGoogle Scholar
  4. 4.
    Avezaat CJ, van Eijndhoven JH, Wyper DJ. Cerebrospinal fluid pulse pressure, intracranial volume-pressure relationships. J Neurol Neurosurg Psychiatry. 1979;42(8):687–700.PubMedCrossRefGoogle Scholar
  5. 5.
    Marmarou A, Shulman K, Rosende RM. A nonlinear analysis of the cerebrospinal fluid system, intracranial pressure dynamics. J Neurosurg. 1978;48(3):332–44.PubMedCrossRefGoogle Scholar
  6. 6.
    Holm S, Eide PK. The frequency domain versus time domain methods for processing of intracranial pressure (ICP) signals. Med Eng Phys. 2008;30(2):164–70.PubMedCrossRefGoogle Scholar
  7. 7.
    Eide PK, Sorteberg W. Intracranial pressure levels, single wave amplitudes, Glasgow Coma Score, Glasgow Outcome Score after subarachnoid haemorrhage. Acta Neurochir (Wien). 2006;148(12):1267–75.CrossRefGoogle Scholar
  8. 8.
    Bentsen G, Stubhaug A, Eide PK. Differential effects of osmotherapy on static, pulsatile intracranial pressure. Crit Care Med. 2008;36(8):2414–9.PubMedCrossRefGoogle Scholar
  9. 9.
    Eide PK, Brean A. Intracranial pulse pressure amplitude levels determined during preoperative assessment of subjects with possible idiopathic normal pressure hydrocephalus. Acta Neurochir (Wien). 2006;148(11):1151–6.CrossRefGoogle Scholar
  10. 10.
    Carrera E, Kim DJ, Castellani G, et al. What shapes pulse amplitude of intracranial pressure? J Neurotrauma. 2010;27(2):317–24.PubMedCrossRefGoogle Scholar
  11. 11.
    Piper IR, Miller JD, Dearden NM, Leggate JR, Robertson I. Systems analysis of cerebrovascular pressure transmission: an observational study in head-injured patients. J Neurosurg. 1990;73(6):871–80.PubMedCrossRefGoogle Scholar
  12. 12.
    Czosnyka M, Smielewski P, Piechnik S, Steiner LA, Pickard JD. Cerebral autoregulation following head injury. J Neurosurg. 2001;95(5):756–63.PubMedCrossRefGoogle Scholar
  13. 13.
    Eide PK, Egge A, Due-Tonnessen BJ, Helseth E. Is intracranial pressure waveform analysis useful in the management of pediatric neurosurgical patients? Pediatr Neurosurg. 2007;43(6):472–81.PubMedCrossRefGoogle Scholar
  14. 14.
    Czosnyka M, Pickard JD. Monitoring interpretation of intracranial pressure. J Neurol Neurosurg Psychiatry. 2004;75(6):813–21.PubMedCrossRefGoogle Scholar
  15. 15.
    Eide PK, Park EH, Madsen JR. Arterial blood pressure vs intracranial pressure in normal pressure hydrocephalus. Acta Neurol Scand. 2010;122(4):262–9.PubMedCrossRefGoogle Scholar
  16. 16.
    Madsen JR, Egnor M, Zou R. Cerebrospinal fluid pulsatility and hydrocephalus: the fourth circulation. Clin Neurosurg. 2006;53:48–52.PubMedGoogle Scholar
  17. 17.
    Czosnyka M, Smielewski P, Kirkpatrick P, Menon DK, Pickard JD. Monitoring of cerebral autoregulation in head-injured patients. Stroke. 1996;27(10):1829–34.PubMedCrossRefGoogle Scholar
  18. 18.
    Steiner LA, Czosnyka M, Piechnik SK, et al. Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury. Crit Care Med. 2002;30(4):733–8.PubMedCrossRefGoogle Scholar
  19. 19.
    Menon DK. Cerebral protection in severe brain injury: physiological determinants of outcome and their optimisation. Br Med Bull. 1999;55(1):226–58.PubMedCrossRefGoogle Scholar
  20. 20.
    Czosnyka M, Balestreri M, Steiner L, et al. Age intracranial pressure, autoregulation, outcome after brain trauma. J Neurosurg. 2005;102(3):450–4.PubMedCrossRefGoogle Scholar
  21. 21.
    Lofgren J, Von EC, Zwetnow NN. The pressure-volume curve of the cerebrospinal fluid space in dogs. Acta Neurol Scand. 1973;49(5):557–74.PubMedGoogle Scholar
  22. 22.
    Carrera E, Kim DJ, Castellani G, et al. Effect of hyper- and hypocapnia on cerebral arterial compliance in normal subjects. J Neuroimaging. 2009.Google Scholar
  23. 23.
    Czosnyka M, Guazzo E, Whitehouse M, et al. Significance of intracranial pressure waveform analysis after head injury. Acta Neurochir (Wien). 1996;138(5):531–41.CrossRefGoogle Scholar
  24. 24.
    Czosnyka M, Smielewski P, Kirkpatrick P, Laing RJ, Menon D, Pickard JD. Continuous assessment of the cerebral vasomotor reactivity in head injury. Neurosurgery. 1997;41(1):11–7.PubMedCrossRefGoogle Scholar
  25. 25.
    Rosner MJ. Role of cerebral perfusion pressure in acute brain trauma. Crit Care Med. 1996;24(7):1274–6.PubMedCrossRefGoogle Scholar

Copyright information

© Springer Science+Business Media, LLC 2011

Authors and Affiliations

  • D. K. Radolovich
    • 1
    • 2
    Email author
  • M. J. H. Aries
    • 1
    • 3
  • G. Castellani
    • 1
    • 4
  • A. Corona
    • 5
  • A. Lavinio
    • 6
  • P. Smielewski
    • 1
  • J. D. Pickard
    • 1
  • M. Czosnyka
    • 1
    • 7
  1. 1.Neurosurgical Unit, Department of Clinical NeurosciencesUniversity of CambridgeCambridgeUK
  2. 2.Department of Intensive CareIRCCS Policlinico San MatteoPaviaItaly
  3. 3.Department of NeurologyUniversity Medical Centre GroningenGroningenThe Netherlands
  4. 4.Department of Anaesthesia and Intensive CareInstituto Europeo Di OncologiaMilanItaly
  5. 5.Department of Intensive CareAzienda Ospedaliera L SaccoMilanItaly
  6. 6.Neurosciences Critical Care UnitAddenbrooke’s HospitalCambridgeUK
  7. 7.ISEWarsaw University of TechnologyWarsawPoland

Personalised recommendations