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      Optimal cerebral perfusion pressure via transcranial Doppler in TBI: application of robotic technology

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          Abstract

          Individualized cerebral perfusion pressure (CPP) targets may be derived via assessing the minimum of the parabolic relationship between an index of cerebrovascular reactivity and CPP. This minimum is termed the optimal CPP (CPPopt), and literature suggests that the further away CPP is from CPPopt, the worse is clinical outcome in adult traumatic brain injury (TBI). Typically, CPPopt estimation is based on intracranial pressure (ICP)-derived cerebrovascular reactivity indices, given ICP is commonly measured and provides continuous long duration data streams. The goal of this study is to describe for the first time the application of robotic transcranial Doppler (TCD) and the feasibility of determining CPPopt based on TCD autoregulation indices.

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          The online version of this article (10.1007/s00701-018-3687-5) contains supplementary material, which is available to authorized users.

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          Continuous monitoring of cerebrovascular pressure reactivity allows determination of optimal cerebral perfusion pressure in patients with traumatic brain injury.

          Mark D. Chatfield, Jennifer Steiner, Piotr Smielewski … (2002)
          To define optimal cerebral perfusion pressure (CPPOPT) in individual head-injured patients using continuous monitoring of cerebrovascular pressure reactivity. To test the hypothesis that patients with poor outcome were managed at a cerebral perfusion pressure (CPP) differing more from their CPPOPT than were patients with good outcome. Retrospective analysis of prospectively collected data. Neurosciences critical care unit of a university hospital. A total of 114 head-injured patients admitted between January 1997 and August 2000 with continuous monitoring of mean arterial blood pressure (MAP) and intracranial pressure (ICP). MAP, ICP, and CPP were continuously recorded and a pressure reactivity index (PRx) was calculated online. PRx is the moving correlation coefficient recorded over 4-min periods between averaged values (6-sec periods) of MAP and ICP representing cerebrovascular pressure reactivity. When cerebrovascular reactivity is intact, PRx has negative or zero values, otherwise PRx is positive. Outcome was assessed at 6 months using the Glasgow Outcome Scale. A total of 13,633 hrs of data were recorded. CPPOPT was defined as the CPP where PRx reaches its minimum value when plotted against CPP. Identification of CPPOPT was possible in 68 patients (60%). In 22 patients (27%), CPPOPT was not found because it presumably lay outside the studied range of CPP. Patients' outcome correlated with the difference between CPP and CPPOPT for patients who were managed on average below CPPOPT (r =.53, p <.001) and for patients whose mean CPP was above CPPOPT (r = -.40, p <.05). CPPOPT could be identified in a majority of patients. Patients with a mean CPP close to CPPOPT were more likely to have a favorable outcome than those whose mean CPP was more different from CPPOPT. We propose use of the criterion of minimal achievable PRx to guide future trials of CPP oriented treatment in head injured patients.
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            Non-invasive Monitoring of Intracranial Pressure Using Transcranial Doppler Ultrasonography: Is It Possible?

            Danilo Cardim, C. Robba, M. Bohdanowicz … (2016)
            Although intracranial pressure (ICP) is essential to guide management of patients suffering from acute brain diseases, this signal is often neglected outside the neurocritical care environment. This is mainly attributed to the intrinsic risks of the available invasive techniques, which have prevented ICP monitoring in many conditions affecting the intracranial homeostasis, from mild traumatic brain injury to liver encephalopathy. In such scenario, methods for non-invasive monitoring of ICP (nICP) could improve clinical management of these conditions. A review of the literature was performed on PUBMED using the search keywords ‘Transcranial Doppler non-invasive intracranial pressure.’ Transcranial Doppler (TCD) is a technique primarily aimed at assessing the cerebrovascular dynamics through the cerebral blood flow velocity (FV). Its applicability for nICP assessment emerged from observation that some TCD-derived parameters change during increase of ICP, such as the shape of FV pulse waveform or pulsatility index. Methods were grouped as: based on TCD pulsatility index; aimed at non-invasive estimation of cerebral perfusion pressure and model-based methods. Published studies present with different accuracies, with prediction abilities (AUCs) for detection of ICP ≥20 mmHg ranging from 0.62 to 0.92. This discrepancy could result from inconsistent assessment measures and application in different conditions, from traumatic brain injury to hydrocephalus and stroke. Most of the reports stress a potential advantage of TCD as it provides the possibility to monitor changes of ICP in time. Overall accuracy for TCD-based methods ranges around ±12 mmHg, with a great potential of tracing dynamical changes of ICP in time, particularly those of vasogenic nature.
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              Critical thresholds for transcranial Doppler indices of cerebral autoregulation in traumatic brain injury.

              Karol P. Budohoski, Peter Smielewski, B. A. Matta … (2011)
              Transcranial Doppler-derived indices of cerebral autoregulation are related to outcome after TBI. We analyzed our retrospective material to identify thresholds discriminative of outcome for these indices. 248 sedated and ventilated patients after head injury were eligible for the study. The indices of autoregulation derived from transcranial Doppler were calculated as correlation coefficients of blood flow velocity with cerebral perfusion pressure (index Mx) or arterial blood pressure (index Mxa). 2 × 2 tables were created grouping patients according to survival-death or favorable-unfavorable outcomes and varying thresholds for Mx and Mxa. Pearson's chi-square was calculated. Thresholds returning the highest chi-square value were assumed to have the best discriminative value between survival-death and favorable-unfavorable outcomes. Mx and Mxa demonstrated that worse autoregulation is associated with poorer outcome and greater mortality (P = 0.0033 for Mx and P = 0.047 for Mxa). Both indices were more effective for prediction of favorable outcome than mortality. Chi-square for Mx showed a double peak with thresholds at 0.05 and 0.3. Mxa had only one peak at 0.3. Peak chi-square for Mx (11.3) was greater than for Mxa (8.7), indicating that Mx was a better discriminant of outcome than Mxa. We propose that Mx greater than 0.3 indicates definitely disturbed autoregulation and lower than 0.05 good autoregulation. For values between 0.05 and 0.3 the state of autoregulation is uncertain.
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                Author and article information

                Contributors
                Frederick A. Zeiler:
                ORCID: http://orcid.org/0000-0003-1737-0510
                umzeiler@myumanitoba.ca
                Marek Czosnyka: mc141@medschl.cam.ac.uk
                Peter Smielewski: ps10011@cam.ac.uk
                Journal
                Journal ID (nlm-ta): Acta Neurochir (Wien)
                Journal ID (iso-abbrev): Acta Neurochir (Wien)
                Title: Acta Neurochirurgica
                Publisher: Springer Vienna (Vienna )
                ISSN (Print): 0001-6268
                ISSN (Electronic): 0942-0940
                Publication date (Electronic): 29 September 2018
                Publication date PMC-release: 29 September 2018
                Publication date (Print): 2018
                Volume: 160
                Issue: 11
                Pages: 2149-2157
                Affiliations
                [1 ]ISNI 0000000121885934, GRID grid.5335.0, Division of Anaesthesia, Addenbrooke’s Hospital, , University of Cambridge, ; Cambridge, UK
                [2 ]ISNI 0000 0004 1936 9609, GRID grid.21613.37, Department of Surgery, Rady Faculty of Health Sciences, , University of Manitoba, ; Winnipeg, MB Canada
                [3 ]ISNI 0000 0004 1936 9609, GRID grid.21613.37, Clinician Investigator Program, Rady Faculty of Health Sciences, , University of Manitoba, ; Winnipeg, MB Canada
                [4 ]ISNI 0000000121885934, GRID grid.5335.0, Division of Neurosurgery, Department of Clinical Neurosciences, Addenbrooke’s Hospital, , University of Cambridge, ; Cambridge, CB2 0QQ UK
                [5 ]ISNI 0000000099214842, GRID grid.1035.7, Institute of Electronic Systems, , Warsaw University of Technology, ; Warsaw, Poland
                Author information
                http://orcid.org/0000-0003-1737-0510
                Article
                Publisher ID: 3687
                DOI: 10.1007/s00701-018-3687-5
                PMC ID: 6209007
                PubMed ID: 30267208
                SO-VID: cd193ac9-5d28-424d-b699-8ec24f572268
                Copyright © © The Author(s) 2018
                License:

                Open Access This article is distributed under the terms of the Creative Commons Attribution 4.0 International License (http://creativecommons.org/licenses/by/4.0/), which permits unrestricted use, distribution, and reproduction in any medium, provided you give appropriate credit to the original author(s) and the source, provide a link to the Creative Commons license, and indicate if changes were made.

                History
                Date received : 29 July 2018
                Date accepted : 20 September 2018
                Funding
                Funded by: University of Cambridge
                Categories
                Subject: Case Report - Brain trauma
                Custom metadata
                issue-copyright-statement © Springer-Verlag GmbH Austria, part of Springer Nature 2018

                ScienceOpen disciplines: Surgery
                Keywords: cpp optimum,robotic transcranial doppler,tcd,traumatic brain injury,tbi
                Data availability:
                ScienceOpen disciplines: Surgery
                Keywords: cpp optimum, robotic transcranial doppler, tcd, traumatic brain injury, tbi

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