Continuous Monitoring of Cerebrovascular Pressure-Reactivity in Head Injury
Objective: Cerebrovascular vasomotor reactivity reflects changes in smooth muscle tone in the arterial wall in response to changes in transmural pressure or concentration of carbon dioxide in blood. We have investigated whether slow waves in ABP and ICP m
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Continuous Monitoring of Cerebrovascular Pressure-Reactivity in Head Injury M. Czosnyka, P. Smielewski, P. Kirkpatrick, S. Piechnik, R. Laing, and J. D. Pickard MRC Cambridge Centre for Brain Repair and Academic Neurosurgical Unit Addenbrooke's Hospital, Cambridge, u.K.
Summary Objective: Cerebrovascular vasomotor reactivity reflects changes in smooth muscle tone in the arterial wall in response to changes in transmural pressure or concentration of carbon dioxide in blood, We have investigated whether slow waves in ABP and ICP may be used to derive an index which reflects reactivity of vessels to changes in arterial blood pressure. Method: A method for the continuous monitoring of the association between slow spontaneous waves in ICP and AP has been adopted in a group of 98 head injured patients. ABP, ICP and transcranial Doppler blood flow velocity (FV) in the middle cerebral artery was recorded daily (20 to 120 minutes time periods). A Pressure-Reactivity Index (PRx) was calculated as a moving correlation coefficient between 40 consecutive samples of values for ICP and ABP averaged over 5 seconds. A moving correlation coefficient between spontaneous fluctuations of mean FV and CPP (Mx), which was previously reported to describe cerebral blood flow autoregulation, was also calculated. In an additional 25 patients, PRx was calculated and recorded continuously along with mean IC? AS? and parameters describing ICP waveform. Results: A positive PRx correlated with high ICP (r = 0.366; P < 0.001), low admission GCS (r = 0.29: p < 0.01), and poor outcome at 6 months after injury (r = 0.48; P < 0.00001). During the first two days following injury, PRx was positive (p < 0.05) in patients with unfavourable outcome. The correlation between PRx and Mx (r = 0.63) was highly significant (p < 0.000001). Continuous recordings demonstrated that PRx was able to indicate individual thresholds of vascular reactivity for CPP, ICP, and ventilation parameters. Conclusion: Computer analysis of slow waves in ABP and ICP is able to provide a continuous indcx of cerebrovascular reactivity to changes in arterial pressure, which is of prognostic significance. Keywords: Head injury; pressure reactivity; Pressure-Reactivity Index (PRx); vasomotor reactivity.
Introduction Cerebrovascular reactiVity to changes in arterial blood pressure describes the ability of vascular
smooth muscle to change basal tone in response to variation in transmural pressure. When the cerebral autoregulatory reserve nears exhaustion, cerebral blood flow becomes unstable. However, vessels may still show responses to a further reduction in perfusion pressure of changes in concentration of carbon dioxide [3,6]. Vascular responses continue to occur outside the range of a stable cerebral blood flow, i.e. outside the limits of cerebral autoregulation [6]. Slow fluctuations in ABP, lasting from 30 seconds to a few minutes, is almost always present in ventilated patients [5-8], and the rate of change observed is usually sufficient to provoke a noticeable vasomotor response [
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