Optimal Cerebral Perfusion Pressure During Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage

Media type: E-Article
Title: Optimal Cerebral Perfusion Pressure During Delayed Cerebral Ischemia After Aneurysmal Subarachnoid Hemorrhage
Contributor: Weiss, Miriam; Albanna, Walid; Conzen, Catharina; Megjhani, Murad; Tas, Jeanette; Seyfried, Katharina; Kastenholz, Nick; Veldeman, Michael; Schmidt, Tobias Philip; Schulze-Steinen, Henna; Wiesmann, Martin; Clusmann, Hans; Park, Soojin; Aries, Marcel; Schubert, Gerrit Alexander
imprint: Ovid Technologies (Wolters Kluwer Health), 2022
Published in: Critical Care Medicine
Language: English
DOI: 10.1097/ccm.0000000000005396
ISSN: 0090-3493
Origination:
Footnote:
Description: <jats:sec> <jats:title>OBJECTIVES:</jats:title> <jats:p>The recommendation of induced hypertension for delayed cerebral ischemia treatment after aneurysmal subarachnoid hemorrhage has been challenged recently and ideal pressure targets are missing. A new concept advocates an individual cerebral perfusion pressure where cerebral autoregulation functions best to ensure optimal global perfusion. We characterized optimal cerebral perfusion pressure at time of delayed cerebral ischemia and tested the conformity of induced hypertension with this target value.</jats:p> </jats:sec> <jats:sec> <jats:title>DESIGN:</jats:title> <jats:p>Retrospective analysis of prospectively collected data.</jats:p> </jats:sec> <jats:sec> <jats:title>SETTING:</jats:title> <jats:p>University hospital neurocritical care unit.</jats:p> </jats:sec> <jats:sec> <jats:title>PATIENTS:</jats:title> <jats:p>Thirty-nine aneurysmal subarachnoid hemorrhage patients with invasive neuromonitoring (20 with delayed cerebral ischemia, 19 without delayed cerebral ischemia).</jats:p> </jats:sec> <jats:sec> <jats:title>INTERVENTIONS:</jats:title> <jats:p>Induced hypertension greater than 180 mm Hg systolic blood pressure.</jats:p> </jats:sec> <jats:sec> <jats:title>MEASUREMENTS AND MAIN RESULTS:</jats:title> <jats:p>Changepoint analysis was used to calculate significant changes in cerebral perfusion pressure, optimal cerebral perfusion pressure, and the difference of cerebral perfusion pressure and optimal cerebral perfusion pressure 48 hours before delayed cerebral ischemia diagnosis. Optimal cerebral perfusion pressure increased 30 hours before the onset of delayed cerebral ischemia from 82.8 ± 12.5 to 86.3 ± 11.4 mm Hg (<jats:italic toggle="yes">p</jats:italic> < 0.05). Three hours before delayed cerebral ischemia, a changepoint was also found in the difference of cerebral perfusion pressure and optimal cerebral perfusion pressure (decrease from –0.2 ± 11.2 to –7.7 ± 7.6 mm Hg; <jats:italic toggle="yes">p</jats:italic> < 0.05) with a corresponding increase in pressure reactivity index (0.09 ± 0.33 to 0.19 ± 0.37; <jats:italic toggle="yes">p</jats:italic> < 0.05). Cerebral perfusion pressure at time of delayed cerebral ischemia was lower than in patients without delayed cerebral ischemia in a comparable time frame (cerebral perfusion pressure delayed cerebral ischemia 81.4 ± 8.3 mm Hg, no delayed cerebral ischemia 90.4 ± 10.5 mm Hg; <jats:italic toggle="yes">p</jats:italic> < 0.05). Inducing hypertension resulted in a cerebral perfusion pressure above optimal cerebral perfusion pressure (+12.4 ± 8.3 mm Hg; <jats:italic toggle="yes">p</jats:italic> < 0.0001). Treatment response (improvement of delayed cerebral ischemia: induced hypertension<jats:sup>+</jats:sup> [<jats:italic toggle="yes">n</jats:italic> = 15] or progression of delayed cerebral ischemia: induced hypertension<jats:sup>–</jats:sup> [<jats:italic toggle="yes">n</jats:italic> = 5]) did not correlate to either absolute values of cerebral perfusion pressure or optimal cerebral perfusion pressure, nor the resulting difference (cerebral perfusion pressure [<jats:italic toggle="yes">p</jats:italic> = 0.69]; optimal cerebral perfusion pressure [<jats:italic toggle="yes">p</jats:italic> = 0.97]; and the difference of cerebral perfusion pressure and optimal cerebral perfusion pressure [<jats:italic toggle="yes">p</jats:italic> = 0.51]).</jats:p> </jats:sec> <jats:sec> <jats:title>CONCLUSIONS:</jats:title> <jats:p>At the time of delayed cerebral ischemia occurrence, there is a significant discrepancy between cerebral perfusion pressure and optimal cerebral perfusion pressure with worsening of autoregulation, implying inadequate but identifiable individual perfusion. Standardized induction of hypertension resulted in cerebral perfusion pressures that exceeded individual optimal cerebral perfusion pressure in delayed cerebral ischemia patients. The potential benefit of individual blood pressure management guided by autoregulation-based optimal cerebral perfusion pressure should be explored in future intervention studies.</jats:p> </jats:sec>

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