Skip to main content


Log in

Continuous Cerebral Blood Flow Autoregulation Monitoring in Patients Undergoing Liver Transplantation

  • Original Article
  • Published:
Neurocritical Care Aims and scope Submit manuscript



Clinical monitoring of cerebral blood flow (CBF) autoregulation in patients undergoing liver transplantation may provide a means for optimizing blood pressure to reduce the risk of brain injury. The purpose of this pilot project is to test the feasibility of autoregulation monitoring with transcranial Doppler (TCD) and near-infrared spectroscopy (NIRS) in patients undergoing liver transplantation and to assess changes that may occur perioperatively.


We performed a prospective observational study in 9 consecutive patients undergoing orthotopic liver transplantation. Patients were monitored with TCD and NIRS. A continuous Pearson’s correlation coefficient was calculated between mean arterial pressure (MAP) and CBF velocity and between MAP and NIRS data, rendering the variables mean velocity index (Mx) and cerebral oximetry index (COx), respectively. Both Mx and COx were averaged and compared during the dissection phase, anhepatic phase, first 30 min of reperfusion, and remaining reperfusion phase. Impaired autoregulation was defined as Mx ≥ 0.4.


Autoregulation was impaired in one patient during all phases of surgery, in two patients during the anhepatic phase, and in one patient during reperfusion. Impaired autoregulation was associated with a MELD score >15 (p = 0.015) and postoperative seizures or stroke (p < 0.0001). Analysis of Mx categorized in 5 mmHg bins revealed that MAP at the lower limit of autoregulation (MAP when Mx increased to ≥ 0.4) ranged between 40 and 85 mmHg. Average Mx and average COx were significantly correlated (p = 0.0029). The relationship between COx and Mx remained when only patients with bilirubin >1.2 mg/dL were evaluated (p = 0.0419). There was no correlation between COx and baseline bilirubin (p = 0.2562) but MELD score and COx were correlated (p = 0.0458). Average COx was higher for patients with a MELD score >15 (p = 0.073) and for patients with a neurologic complication than for patients without neurologic complications (p = 0.0245).


These results suggest that autoregulation is impaired in patients undergoing liver transplantation, even in the absence of acute, fulminant liver failure. Identification of patients at risk for neurologic complications after surgery may allow for prompt neuroprotective interventions, including directed pressure management.

This is a preview of subscription content, log in via an institution to check access.

Access this article

Price excludes VAT (USA)
Tax calculation will be finalised during checkout.

Instant access to the full article PDF.

Fig. 1
Fig. 2

Similar content being viewed by others


  1. Czosnyka M, Brady K, Reinhard M, Smielewski P, Steiner LA. Monitoring of cerebrovascular autoregulation: facts, myths, and missing links. Neurocrit Care. 2009;10(3):373–86.

    Article  PubMed  Google Scholar 

  2. van Mook WN, Rennenberg RJ, Schurink GW, van Oostenbrugge RJ, Mess WH, Hofman PA, de Leeuw PW. Cerebral hyperperfusion syndrome. Lancet Neurol. 2005;4(12):877–88.

    Article  PubMed  Google Scholar 

  3. Joshi B, Brady K, Lee J, Easley B, Panigrahi R, Smielewski P, Czosnyka M, Hogue CW Jr. Impaired autoregulation of cerebral blood flow during rewarming from hypothermic cardiopulmonary bypass and its potential association with stroke. Anesth Analg. 2010;110(2):321–8.

    Article  PubMed  Google Scholar 

  4. 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. discussion 17–19.

    Article  PubMed  CAS  Google Scholar 

  5. Steiner LA, Czosnyka M, Piechnik SK, Smielewski P, Chatfield D, Menon DK, Pickard JD. 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.

    Article  PubMed  Google Scholar 

  6. Steadman RH, Van Rensburg A, Kramer DJ. Transplantation for acute liver failure: perioperative management. Curr Opin Organ Transpl. 2010;15(3):368–73.

    Article  Google Scholar 

  7. Dhiman RK, Kurmi R, Thumburu KK, Venkataramarao SH, Agarwal R, Duseja A, Chawla Y. Diagnosis and prognostic significance of minimal hepatic encephalopathy in patients with cirrhosis of liver. Dig Dis Sci. 2010;55(8):2381–90.

    Article  PubMed  Google Scholar 

  8. Joshi B, Ono M, Brown C, Brady K, Easley RB, Yenokyan G, Gottesman RF, Hogue CW. Predicting the limits of cerebral autoregulation during cardiopulmonary bypass. Anesth Analg. 2012;114(3):503–10.

    Article  PubMed  Google Scholar 

  9. Brady KM, Lee JK, Kibler KK, Smielewski P, Czosnyka M, Easley RB, Koehler RC, Shaffner DH. Continuous time-domain analysis of cerebrovascular autoregulation using near-infrared spectroscopy. Stroke. 2007;38(10):2818–25.

    Article  PubMed  Google Scholar 

  10. Brady K, Joshi B, Zweifel C, Smielewski P, Czosnyka M, Easley RB, Hogue CW Jr. Real-time continuous monitoring of cerebral blood flow autoregulation using near-infrared spectroscopy in patients undergoing cardiopulmonary bypass. Stroke. 2010;41(9):1951–6.

    Article  PubMed  Google Scholar 

  11. Song JG, Jeong SM, Shin WJ, Jun IG, Shin K, Huh IY, Kim YK, Hwang GS. Laboratory variables associated with low near-infrared cerebral oxygen saturation in icteric patients before liver transplantation surgery. Anesth Analg. 2011;112(6):1347–52.

    Article  PubMed  CAS  Google Scholar 

  12. Raschke RA, Curry SC, Rempe S, Gerkin R, Little E, Manch R, Wong M, Ramos A, Leibowitz AI. Results of a protocol for the management of patients with fulminant liver failure. Crit Care Med. 2008;36(8):2244–8.

    Article  PubMed  Google Scholar 

  13. Steiner LA, Coles JP, Johnston AJ, Chatfield DA, Smielewski P, Fryer TD, Aigbirhio FI, Clark JC, Pickard JD, Menon DK, et al. Assessment of cerebrovascular autoregulation in head-injured patients: a validation study. Stroke. 2003;34(10):2404–9.

    Article  PubMed  Google Scholar 

  14. Larsen FS, Ejlersen E, Strauss G, Rasmussen A, Kirkegaard P, Hansen BA, Secher N. Cerebrovascular metabolic autoregulation is impaired during liver transplantation. Transplantation. 1999;68(10):1472–6.

    Article  PubMed  CAS  Google Scholar 

  15. Durham S, Yonas H, Aggarwal S, Darby J, Kramer D. Regional cerebral blood flow and CO2 reactivity in fulminant hepatic failure. J Cereb Blood Flow Metab. 1995;15(2):329–35.

    Article  PubMed  CAS  Google Scholar 

  16. Ardizzone G, Arrigo A, Panaro F, Ornis S, Colombi R, Distefano S, Jarzembowski TM, Cerruti E. Cerebral hemodynamic and metabolic changes in patients with fulminant hepatic failure during liver transplantation. Transpl Proc. 2004;36(10):3060–4.

    Article  CAS  Google Scholar 

  17. Zweifel C, Castellani G, Czosnyka M, Carrera E, Brady KM, Kirkpatrick PJ, Pickard JD, Smielewski P. Continuous assessment of cerebral autoregulation with near-infrared spectroscopy in adults after subarachnoid hemorrhage. Stroke. 2010;41(9):1963–8.

    Article  PubMed  Google Scholar 

  18. Nissen P, Pacino H, Frederiksen HJ, Novovic S, Secher NH. Near-infrared spectroscopy for evaluation of cerebral autoregulation during orthotopic liver transplantation. Neurocrit Care. 2009;11(2):235–41.

    Article  PubMed  Google Scholar 

  19. Patel P, Drummond J. Cerebral physiology and the effects of anesthetics and techniques. In: Miller RD, editor. Anesthesia, vol. 1. 6th ed. Philadelphia: Elsevier Churchill Livingstone; 2005.

    Google Scholar 

  20. Jalan R, Olde Damink SW, Deutz NE, Hayes PC, Lee A. Restoration of cerebral blood flow autoregulation and reactivity to carbon dioxide in acute liver failure by moderate hypothermia. Hepatology. 2001;34(1):50–4.

    Article  PubMed  CAS  Google Scholar 

Download references

Author information

Authors and Affiliations


Corresponding author

Correspondence to Charles W. Hogue.

Additional information

Clinical Trials Registration: NCT01425385 at

Rights and permissions

Reprints and permissions

About this article

Cite this article

Zheng, Y., Villamayor, A.J., Merritt, W. et al. Continuous Cerebral Blood Flow Autoregulation Monitoring in Patients Undergoing Liver Transplantation. Neurocrit Care 17, 77–84 (2012).

Download citation

  • Published:

  • Issue Date:

  • DOI: