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“Optimal Cerebral Perfusion Pressure” in Poor Grade Patients After Subarachnoid Hemorrhage

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Abstract

Background

Cerebrovascular pressure reactivity depends on cerebral perfusion pressure (CPP), with the optimal CPP (CPPopt) defined as pressure at which cerebrovascular reactivity is functioning optimally, reaching minimal value of pressure reactivity index (PRx). The study investigates the association between vasospasm, PRx, and CPPopt in poor grade patients (WFNS 4&5) after subarachnoid hemorrhage (SAH).

Methods

Data of intracranial pressure (ICP), arterial blood pressure (ABP), and flow velocities (FV) in the Middle Cerebral Artery (MCA) on transcranial Doppler from 42 SAH patients were analyzed retrospectively. PRx was calculated as a correlation coefficient between 10 s mean values of ABP and ICP calculated over a moving 3 min window. Data recorded during the first 48 h were available in 25 cases and during the first 3 days in 29 patients. Recordings obtained from day 4 to day 24 were available in 23 patients.

Results

PRx at optimal CPP measured during the first 48 h showed better cerebrovascular reactivity in patients who were alive at 3 months after ictus than in those who died (PRx value −0.17 ± 0.05 vs. 0.1 ± 0.09; P < 0.01). PRx below zero at CPPopt during the first 48 h had 87.5% positive predictive value for survival. CPPopt was lower before than during vasospasm (78 ± 3 mmHg, N = 29 vs. 98 ± 4 mmHg; N = 17, P < 0.0001). The overall correlation between CPPopt and Lindegaard ratio was positive (R = 0.39; P < 0.01; N = 45).

Conclusion

Most WFNS 4&5 grade SAH patients with PRx below zero at optimal CPP during the first 48 h after ictus survived. Optimal CPP increases during vasospasm.

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Acknowledgments

The authors are in debt to all the team participating in data collection : Mrs. Pippa Al-Rawi, Dr. Ming-Yuan Tseng, Mrs. Dott Chatfield, Mrs. Joanne Outtrim, Mrs. Anne Manktelow, Mrs. Helen Seeley, Mrs. Carole Turner, Dr. Marcella Balestreri, Dr. Magda Hiler, Dr. Luzius Steiner, Dr. Eric Schmidt, Dr. Stefan Piechnik, Dr. Andreas Raabe, Mr. Eric Guazzo, Prof. David Menon, Prof. Arun Gupta, Dr. Basil Matta, Mr. Peter Kirkpatrick, Mr. Ivan Timofeev, Mr. Pwawanjit Minhas, and all nursing and research staff of NCCU and Wolfson Brain Imaging Centre. The project was supported by National institute of Health Research Biomedical Research Centre, Cambridge University Hospital Foundation Trust—Neurosciences Theme and Senior Investigaor Award (JDP). PB was supported by “Fond de perfectionnement” of the Geneva University Hospital, The “Fond Ernst and Lucie Schmidheiny” and the “Société Académique de Genève”.

Disclosure

ICM+ software (www.neurosurg.cam.ac.uk/icmplus) is licensed by University of Cambridge and PS and MC have financial interest in a fraction of licensing fee.

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Authors and Affiliations

  1. Academic Neurosurgical Unit, Department of Neurosurgery, Addenbrooke’s Hospital, University of Cambridge, Box 167, Cambridge, CB2 0QQ, UK

    Philippe Bijlenga, Marek Czosnyka, Karol P. Budohoski, Martin Soehle, John D. Pickard, Peter J. Kirkpatrick & Peter Smielewski

  2. Neurochirurgie, Département des neurosciences cliniques, Hôpital Universitaire de Genève, Geneva, Switzerland

    Philippe Bijlenga

  3. Department of Anaesthesiology and Intensive Care Medicine, University of Bonn, Bonn, Germany

    Martin Soehle

  4. Department of Neurosurgery, Bielanski Hospital, Medical Research Centre, Polish Academy of Sciences, Warsaw, Poland

    Karol P. Budohoski

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  1. Philippe Bijlenga
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  2. Marek Czosnyka
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Correspondence to Karol P. Budohoski.

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Bijlenga, P., Czosnyka, M., Budohoski, K.P. et al. “Optimal Cerebral Perfusion Pressure” in Poor Grade Patients After Subarachnoid Hemorrhage. Neurocrit Care 13, 17–23 (2010). https://doi.org/10.1007/s12028-010-9362-1

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