Journal Article

Temporal Dynamics of ICP, CPP, PRx, and CPPopt in High-Grade Aneurysmal Subarachnoid Hemorrhage and the Relation to Clinical Outcome

Lewén, Anders, Svedung Wettervik, Teodor, Enblad, Per, Howells, Timothy, Ronne-Engström, Elisabeth

2021

Overview

Background High intracranial pressure (ICP) and low cerebral perfusion pressure (CPP) may induce secondary brain injury following aneurysmal subarachnoid hemorrhage (aSAH). In the current study, we aimed to determine the temporal incidence of insults above/below certain ICP/CPP thresholds, the role of pressure autoregulation in CPP management (PRx and CPPopt), and the relation to clinical outcome. Methods In this retrospective study, 242 patients were included with aSAH, who were treated in the neurointensive care unit, Uppsala University Hospital, Sweden, 2008–2018, with ICP monitoring the first 10 days post-ictus. Data from ICP, pressure autoregulation (PRx), CPP, and CPPopt (the CPP with the lowest/optimal PRx) were analyzed the first 10 days. The percentage of good monitoring time (GMT) above/below various ICP and CPP thresholds was calculated, e.g., ICP > 20 mm Hg (%), CPP < 60 mm Hg (%), and ∆CPPopt (CPP–CPPopt) < − 10 mm Hg (%). Results Of the 242 patients, 63 (26%) had favorable (GOS-E 5–8) and 179 (74%) had unfavorable (GOS-E 1–4) outcome at 12 months. Higher proportion (GMT) of ICP insults above 20 mm Hg was most common the first 3 days post-ictus and was then independently associated with unfavorable outcome. CPP gradually increased throughout the 10 days post-ictus, and higher proportion of GMT with CPP < 90 mm Hg was independently associated with unfavorable outcome in the late vasospasm phase (days 6.5–10). PRx was above 0 throughout the 10 days and deteriorated in the late vasospasm phase. Higher values were then independently associated with unfavorable outcome. There was no difference in GMT of CPP deviations from CPPopt between the outcome groups. Conclusions Avoiding intracranial hypertension early and maintaining a high CPP in the vasospasm phase when the pressure autoregulation is most disturbed may improve clinical outcome after aSAH.

• Publisher: Springer US,Springer Nature B.V
• Subject: Aneurysms / Blood Pressure / Body temperature / Cerebral perfusion pressure / Cerebrospinal fluid / Cerebrovascular Circulation / Clinical outcome / Clinical outcomes / Critical Care Medicine / Hemorrhage / Humans / Hydrocephalus / Hyperthermia / Intensive / Internal Medicine / Intracranial Pressure / Medicine / Medicine & Public Health / Mortality / Neurointensive care / Neurology / Neurosurgery / Original Work / Pathophysiology / Pressure autoregulation / Retrospective Studies / Secondary insults / Stroke / Subarachnoid hemorrhage / Subarachnoid Hemorrhage - therapy