Optimal cerebral perfusion pressure: are we ready for it? 2013

Christos Lazaridis, and Piotr Smielewski, and Luzius A Steiner, and Ken M Brady, and Peter Hutchinson, and John D Pickard, and Marek Czosnyka
Academic Neurosurgical Unit, University of Cambridge Clinical School, Cambridge, UK. lazaridi@musc.edu

OBJECTIVE Cerebral perfusion pressure (CPP)-oriented therapy and the Lund concept lie on opposite ends of the CPP scale, in the management of head injury. Optimization of CPP by monitoring cerebral vascular pressure reactivity is an alternative approach that may reconcile these two divergent approaches, preventing both injurious hypotension and hypertension with an individualized CPP target. METHODS Indices describing cerebral vascular reactivity or cerebral blood flow autoregulation, derived from intracranial pressure, near-infrared spectroscopy, or transcranial Doppler are reviewed in this manuscript. RESULTS Indices of cerebrovascular reactivity and autoregulation typically converge to a U-shape curve when viewed as a function of CPP, with the best reactivity metrics indicating optimal CPP. In a retrospective study of prospectively collected data from head-injured patients, Steiner et al. demonstrated that a greater distance between averaged over total monitoring time-CPP and optimal CPP, correlated with unfavourable outcome. A recent study of 300 head-injured patients (2003-2009) showed that hypotension below optimal CPP was associated with greater mortality rate, while hypertension above optimal CPP was associated with an increase in severe disability. CONCLUSIONS Pilot studies indicating feasibility of autoregulation-oriented CPP optimization have been performed in adult and paediatric traumatic brain injury, aneurysmal subarachnoid haemorrhage, and in patients undergoing cardiothoracic surgery. It remains to be prospectively demonstrated whether optimal CPP management is able to improve outcome.

UI MeSH Term Description Entries
D007427 Intracranial Pressure Pressure within the cranial cavity. It is influenced by brain mass, the circulatory system, CSF dynamics, and skull rigidity. Intracerebral Pressure,Subarachnoid Pressure,Intracerebral Pressures,Intracranial Pressures,Pressure, Intracerebral,Pressure, Intracranial,Pressure, Subarachnoid,Pressures, Intracerebral,Pressures, Intracranial,Pressures, Subarachnoid,Subarachnoid Pressures
D008991 Monitoring, Physiologic The continuous measurement of physiological processes, blood pressure, heart rate, renal output, reflexes, respiration, etc., in a patient or experimental animal; includes pharmacologic monitoring, the measurement of administered drugs or their metabolites in the blood, tissues, or urine. Patient Monitoring,Monitoring, Physiological,Physiologic Monitoring,Monitoring, Patient,Physiological Monitoring
D002560 Cerebrovascular Circulation The circulation of blood through the BLOOD VESSELS of the BRAIN. Brain Blood Flow,Regional Cerebral Blood Flow,Cerebral Blood Flow,Cerebral Circulation,Cerebral Perfusion Pressure,Circulation, Cerebrovascular,Blood Flow, Brain,Blood Flow, Cerebral,Brain Blood Flows,Cerebral Blood Flows,Cerebral Circulations,Cerebral Perfusion Pressures,Circulation, Cerebral,Flow, Brain Blood,Flow, Cerebral Blood,Perfusion Pressure, Cerebral,Pressure, Cerebral Perfusion
D006259 Craniocerebral Trauma Traumatic injuries involving the cranium and intracranial structures (i.e., BRAIN; CRANIAL NERVES; MENINGES; and other structures). Injuries may be classified by whether or not the skull is penetrated (i.e., penetrating vs. nonpenetrating) or whether there is an associated hemorrhage. Frontal Region Trauma,Head Injuries,Head Trauma,Occipital Region Trauma,Parietal Region Trauma,Temporal Region Trauma,Craniocerebral Injuries,Crushing Skull Injury,Forehead Trauma,Head Injuries, Multiple,Head Injury, Minor,Head Injury, Open,Head Injury, Superficial,Injuries, Craniocerebral,Injuries, Head,Multiple Head Injuries,Occipital Trauma,Open Head Injury,Superficial Head Injury,Trauma, Head,Craniocerebral Injury,Craniocerebral Traumas,Crushing Skull Injuries,Forehead Traumas,Frontal Region Traumas,Head Injuries, Minor,Head Injuries, Open,Head Injuries, Superficial,Head Injury,Head Injury, Multiple,Head Traumas,Injuries, Minor Head,Injuries, Multiple Head,Injuries, Open Head,Injuries, Superficial Head,Injury, Craniocerebral,Injury, Head,Injury, Minor Head,Injury, Multiple Head,Injury, Open Head,Injury, Superficial Head,Minor Head Injuries,Minor Head Injury,Multiple Head Injury,Occipital Region Traumas,Occipital Traumas,Open Head Injuries,Parietal Region Traumas,Region Trauma, Frontal,Region Trauma, Occipital,Region Trauma, Parietal,Region Traumas, Frontal,Region Traumas, Occipital,Region Traumas, Parietal,Skull Injuries, Crushing,Skull Injury, Crushing,Superficial Head Injuries,Temporal Region Traumas,Trauma, Craniocerebral,Trauma, Forehead,Trauma, Frontal Region,Trauma, Occipital,Trauma, Occipital Region,Trauma, Parietal Region,Trauma, Temporal Region,Traumas, Craniocerebral,Traumas, Forehead,Traumas, Frontal Region,Traumas, Head,Traumas, Occipital,Traumas, Occipital Region,Traumas, Parietal Region,Traumas, Temporal Region
D006706 Homeostasis The processes whereby the internal environment of an organism tends to remain balanced and stable. Autoregulation
D006801 Humans Members of the species Homo sapiens. Homo sapiens,Man (Taxonomy),Human,Man, Modern,Modern Man
D014463 Ultrasonography The visualization of deep structures of the body by recording the reflections or echoes of ultrasonic pulses directed into the tissues. Use of ultrasound for imaging or diagnostic purposes employs frequencies ranging from 1.6 to 10 megahertz. Echography,Echotomography,Echotomography, Computer,Sonography, Medical,Tomography, Ultrasonic,Ultrasonic Diagnosis,Ultrasonic Imaging,Ultrasonographic Imaging,Computer Echotomography,Diagnosis, Ultrasonic,Diagnostic Ultrasound,Ultrasonic Tomography,Ultrasound Imaging,Diagnoses, Ultrasonic,Diagnostic Ultrasounds,Imaging, Ultrasonic,Imaging, Ultrasonographic,Imaging, Ultrasound,Imagings, Ultrasonographic,Imagings, Ultrasound,Medical Sonography,Ultrasonic Diagnoses,Ultrasonographic Imagings,Ultrasound, Diagnostic,Ultrasounds, Diagnostic
D019585 Intracranial Hypotension Reduction of CEREBROSPINAL FLUID pressure characterized clinically by ORTHOSTATIC HEADACHE and occasionally by an ABDUCENS NERVE PALSY; HEARING LOSS; NAUSEA; neck stiffness, and other symptoms. This condition may be spontaneous or secondary to CEREBROSPINAL FLUID LEAK; SPINAL PUNCTURE; NEUROSURGICAL PROCEDURES; DEHYDRATION; UREMIA; trauma (see also CRANIOCEREBRAL TRAUMA); and other processes. Chronic hypotension may be associated with subdural hematomas (see HEMATOMA, SUBDURAL) or hygromas. (From Semin Neurol 1996 Mar;16(1):5-10; Adams et al., Principles of Neurology, 6th ed, pp637-8) Intracranial Hypotension, Essential,Intracranial Hypotension, Secondary,Intracranial Hypotension, Spontaneous,CSF Hypovolemia,Cerebrospinal Fluid Hypovolemia,CSF Hypovolemias,Cerebrospinal Fluid Hypovolemias,Essential Intracranial Hypotension,Fluid Hypovolemia, Cerebrospinal,Fluid Hypovolemias, Cerebrospinal,Hypotension, Essential Intracranial,Hypotension, Intracranial,Hypotension, Secondary Intracranial,Hypotension, Spontaneous Intracranial,Hypovolemia, CSF,Hypovolemia, Cerebrospinal Fluid,Hypovolemias, CSF,Hypovolemias, Cerebrospinal Fluid,Secondary Intracranial Hypotension,Spontaneous Intracranial Hypotension
D019586 Intracranial Hypertension Increased pressure within the cranial vault. This may result from several conditions, including HYDROCEPHALUS; BRAIN EDEMA; intracranial masses; severe systemic HYPERTENSION; PSEUDOTUMOR CEREBRI; and other disorders. Elevated ICP (Intracranial Pressure),Elevated Intracranial Pressure,ICP (Intracranial Pressure) Elevation,ICP (Intracranial Pressure) Increase,Intracranial Pressure Increase,Hypertension, Intracranial,ICP, Elevated (Intracranial Pressure),Intracranial Pressure, Elevated,Pressure Increase, Intracranial,Pressure, Elevated Intracranial

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