Frederick A. Zeiler , 1 , 2 , 3 , 8 , 9 , Ari Ercole 1 , Erta Beqiri 3 , Manuel Cabeleira 3 , Marcel Aries 4 , Tommaso Zoerle 5 , Marco Carbonara 5 , Nino Stocchetti 5 , 6 , Peter Smielewski 3 , Marek Czosnyka 3 , 7 , David K. Menon 1 , the CENTER-TBI High Resolution ICU (HR ICU) Sub-Study Participants and Investigators
25 June 2019
Impaired cerebrovascular reactivity in adult traumatic brain injury (TBI) is known to be associated with poor outcome. However, there has yet to be an analysis of the association between the comprehensively assessed intracranial hypertension therapeutic intensity level (TIL) and cerebrovascular reactivity.
Using the Collaborative European Neuro Trauma Effectiveness Research in TBI (CENTER-TBI) high-resolution intensive care unit (ICU) cohort, we derived pressure reactivity index (PRx) as the moving correlation coefficient between slow-wave in ICP and mean arterial pressure, updated every minute. Mean daily PRx, and daily % time above PRx of 0 were calculated for the first 7 days of injury and ICU stay. This data was linked with the daily TIL-Intermediate scores, including total and individual treatment sub-scores. Daily mean PRx variable values were compared for each TIL treatment score via mean, standard deviation, and the Mann U test (Bonferroni correction for multiple comparisons). General fixed effects and mixed effects models for total TIL versus PRx were created to display the relation between TIL and cerebrovascular reactivity.
A total of 249 patients with 1230 ICU days of high frequency physiology matched with daily TIL, were assessed. Total TIL was unrelated to daily PRx. Most TIL sub-scores failed to display a significant relationship with the PRx variables. Mild hyperventilation ( p < 0.0001), mild hypothermia ( p = 0.0001), high levels of sedation for ICP control ( p = 0.0001), and use vasopressors for CPP management ( p < 0.0001) were found to be associated with only a modest decrease in mean daily PRx or % time with PRx above 0.
Cerebrovascular reactivity remains relatively independent of intracranial hypertension therapeutic intensity, suggesting inadequacy of current TBI therapies in modulating impaired autoregulation. These findings support the need for investigation into the molecular mechanisms involved, or individualized physiologic targets (ICP, CPP, or Co2) in order to treat dysautoregulation actively.