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Time spent with impaired autoregulation is linked with outcome in severe infant/paediatric traumatic brain injury

  • Original Article - Brain Injury
  • Published:
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Abstract

Background

It could be shown in traumatic brain injury (TBI) in adults that the functional status of cerebrovascular autoregulation (AR), determined by the pressure reactivity index (PRx), correlates to and even predicts outcome. We investigated PRx, cerebral perfusion pressure (CPP) and intracranial pressure (ICP) and their correlation to outcome in severe infant and paediatric TBI.

Methods

Seventeen patients (range, 1 day to 14 years) with severe TBI (median GCS at presentation, 4) underwent long-term computerised ICP and mean arterial pressure (MAP) monitoring using dedicated software to determine CPP and PRx and optimal CPP (CPP level where PRx shows best autoregulation) continuously. Outcome was determined at discharge and at follow-up using the Glasgow Outcome Scale.

Results

Favourable outcome was reached in eight patients, unfavourable outcome in seven patients. Two patients died. Nine patients underwent decompressive craniectomy to control ICP during Intensive Care Unit treatment. When dichotomised to outcome, no significant difference was found for overall ICP, CPP and PRx. The time with severely impaired AR (PRx >0.2) was significantly longer for patients with unfavourable outcome (64 h vs 6 h, p = 0.001). Continuously impaired AR of ≥24 h and age <1 year was associated to unfavourable outcome. Children with favourable outcome spent the entire monitoring time at or above the optimal CPP.

Conclusions

Integrity of AR has a similar role for outcome after TBI in the paediatric population as in adults. The amount of time spent with deranged AR seems to be associated with outcome; a factor especially critical for infant patients. The results of this preliminary study need to be validated in the future.

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Abbreviations

AR:

cerebrovascular autoregulation

CPP:

cerebral perfusion pressure

DC:

decompressive craniotomy

ICP:

intracranial pressure

MAP:

mean arterial pressure

PRx:

pressure reactivity index

TBI:

traumatic brain injury

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Funding

No funding was received for this research.

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Authors and Affiliations

  1. Section of Paediatric Neurosurgery, Department of Neurosurgery, University Hospital of Tübingen, Hoppe-Seyler-Str. 3, 72076, Tübingen, Germany

    Konstantin Hockel, Jennifer Diedler & Martin U. Schuhmann

  2. Paediatric Intensive Care Medicine, University Children’s Hospital of Tübingen, Tübingen, Germany

    Felix Neunhoeffer & Ellen Heimberg

  3. Department of Paediatric Surgery, University Children’s Hospital of Tübingen, Tübingen, Germany

    Carmen Nagel

Authors
  1. Konstantin Hockel
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  2. Jennifer Diedler
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  3. Felix Neunhoeffer
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  4. Ellen Heimberg
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  5. Carmen Nagel
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  6. Martin U. Schuhmann
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Corresponding author

Correspondence to Konstantin Hockel.

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Conflict of interest

All authors certify that they have no affiliations with or involvement in any organisation or entity with any financial interest, or non-financial interest in the subject matter or materials discussed in this manuscript.

Ethical approval

All procedures performed in studies involving human participants were in accordance with the ethical standards of the institutional and/or national research committee and with the 1964 Helsinki declaration and its later amendments or comparable ethical standards. For this type of study formal consent is not required.

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Comments

This is another work showing that ICP is important but not the major factor. Similarly to the sun or the horizon we believed to be the centre of the world and flat, we were misled.ICP is the obvious visible factor but the essential factor is continuous adequate local perfusion and this is strongly regulated. The hypothesis is that preserved autoregulation and autoregulation buffers protect brain tissue from secondary hypoperfusion. The loss of autoregulation makes it a challenge and, if severe, impossible to keep the perfusion adequate at all times, resulting in successive insults progressively amplifying the initial injury. Autoregulation can be assessed by various tools but PRx seems to have advantages and is probably the most reported. CPPopt is a great concept that, like an index or a medication adjustment to the patient’s weight, normalises the perfusion pressure to the specific conditions of each patient at a specific time. This work adds evidence to the concept of CPPopt driven TBI management and extends it to the paediatric population.It is time for the community to join efforts to rapidly assess formally in a massive multi-centre trial the concept of CPPopt-driven management of TBI patients.

Philippe Bijlenga

Geneve, Switzerland

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Hockel, K., Diedler, J., Neunhoeffer, F. et al. Time spent with impaired autoregulation is linked with outcome in severe infant/paediatric traumatic brain injury. Acta Neurochir 159, 2053–2061 (2017). https://doi.org/10.1007/s00701-017-3308-8

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  • DOI: https://doi.org/10.1007/s00701-017-3308-8

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